complaint·April 20, 2023

Allegation: Facility vehicle is in disrepair LPA conducted a tour of the facility transportation van that was reportedly had recently removed seats to declare to state the van would be a ten-passenger van (1 driver and 9 passengers). LPA requested to review the inspections that have been conducted by California Highway Patrol. Lauren the Executive Director provided LPA with a copy of the chp343 titled Safety Compliance Report/terminal record update that was dated 2015 and indicated that the vehicle would be inactivate and defined as bus. Due to the capacity reduction in the van, annual inspections are not required. A further inspection of the van revealed that, the fire extinguisher was not secured and has the potential to roll around, there were also extra seat belts that were buckled from the seats that were removed and were found to be secured laying on the floor. There were some exposed wires Based on the facility vehicle is in disrepair is SUBSTANTIATED. Allegation: Uncleared adults working at the facility. LPA conducted a review of the staff schedule, LIC 500 and compared it to the facility personnel report summary. LPA found there to be inaccuracies with the staff schedule and the LIC 500, as not all staff on the schedule were not indicated on the LIC 500. LPA observed for Staff #1 (S1) to be working at the at the facility, during LPA’s visit and is noted to have worked/been an employee since July 21, 2022, without having had obtained the proper clearance. S1 current status is "pending". As a result, LPA along with Executive Director Lauren and Assistant Executive Director Shannon escorted S1 off the community grounds, it was explained that they would be removed from the schedule until the proper clearance has been obtained. S1 stated that they were aware and was working on makingThe allegation of uncleared adults working in the facility is SUBSTANTIATED. Allegation: Facility does not maintain accurate and complete resident and employee records/files. LPA conducted a review of seven (7) resident files of the 17 currently admitted to the facility. LPA observed for the resident files to have a completed physician’s report, preplacement appraisal, an assessment needs and services plan, emergency notification identification form, and Admissions agreement. LPA conducted a review of five (5) staff files according to the LIC500 there are a total of (15) staff. According to the table of contents the staff files are to include the training that the staff has received at initial employment and on going required training. LPA observed the following inconsistencies: 1 out of 5 staff files had a training checklist, 2 of the 5 staff records had a CPR/First Aid card showing that training had been received. 3 of the 5 staff files had a copy of the staff identification (DL, ID card). Based on record review the allegation of facility does not maintain accurate and complete resident and employee records/files is SUBSTANTIATED. This too was corrected at the time of the visit, LPA did not observe any flammable liquids other than cleaning agents, that were properly stored, they were on a separate shelf away from the emergency food supply. The allegation of facility does not properly store flammable liquids is UNSUBSTANTIATED. Administrator is not at the facility a sufficient amount of time The facility does not keep a staff schedule indicating when administration would be on grounds. Per the LIC 500 the Administrator Lauren Kabakoff works at the facility Monday-Thursday 10am-7:00pm. Lauren is also on call 24/7. The facility has a second Administrator Shannon Hundley who works Monday-Friday 8am-5pm. Per interviews conducted Lauren is present on the days indicated, and the facility has an additional staff (Shannon) that holds the administrator certificate. Based on observation, interview and record review the allegation is UNSUBSTANTIATED. Facility is not maintained in a clean and sanitary condition. A tour of the physical plant was conducted, and the facility was observed to be clean, clutter and odor free. However, there were resident apartments (11, 16, 17, 24), that were observed to be cluttered and having piles of items such as shoes, papers, and drinking beverages etc. Per the Executive Director Lauren the facility policy is that the residents are encouraged to decorate how they would like and that it is acceptable as long as there is a free pathway to maneuver about the room for fire personnel and other visitors. LPA observed for the pathways to be clear, and free from obstruction. The stated apartments were not observed to be unsanitary or not clean, just had a lot of items placed stacked and or piled throughout the room. Based on observation and interviews the allegation is UNSUBSTANTIATED. Facility has excess trash. LPA conducted a tour of the physical plant and did not observe any excess trash. Per the Executive Director Lauren the dumpster is emptied 2-3 times a week on Mondays, Wednesdays and Fridays. The exterior of the physical plant was observed to be free of trash. The area where the dumpster sits in the back of the facility was clean, there were no stains, odors or lose flying trash observed. Based on observation and interviews the allegation facility has excess trash is UNSUBSTANTIATED. Regarding the allegation of Facility does not provide a safe environment for residents and staff. The facility offers 24/7 supervision, and is a secured perimeter, a code is required to get in and out of the gate/door. Each apartment has a pull cord in all restrooms and all residents are issued a pendant upon admission. The pendant can be worn around the resident's neck. The facility has a Licensed Vocational Nurse that is also on call 24/7. It was alleged that the volunteers do not provide a safe environment. Per Executive Director Lauren the facility does have a total of 10 volunteers. There are not any known instances where the volunteers have mistreated the residents when speaking to them, and socializing during happy hour, and other activities. In addition the residents and staff have not reported any concerns about how the volunteers and their conduct while on grounds. There are some volunteers that come 1 a week and some that come 2 times a month. There was not sufficient evidence to corroborate the allegation, therefore the allegation facility does not provide a safe environment for residents and staff is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of this report was provided to Executive Director Lauren Kabakook. Facility staff are not adequately trained. LPA conducted a review of five (5) staff files according to the LIC500 there are a total of (15) staff. According to the table of contents the staff files a breakdown of training's are to be included in section 8, of the file. The training included would be that the staff has received at initial employment and on going required training LPA observed the following inconsistencies: 1 out of 5 staff files had a training checklist, 2 of the 5 staff records had a CPR/First Aid card showing that training had been received. 3 of the 5 staff files had a copy of the staff identification (DL, ID card). In addition staff #2 (S2)'s CPR/First Aid expired in February 2023. Based on record review the allegation of facility does not maintain accurate and complete resident and employee records/files is SUBSTANTIATED. A substantiated finding means that the preponderance of evidence standard has been met. An exit interview was conducted and a copy of this report, 9099C, 9099D LIC 811, and appeal rights were provided to Executive Director Lauren Kabakook