Complaint·August 30, 2021

Allegation: Staff are not adequately supervising residents Complaint alleged facility staff are locking residents in their bedrooms to substitute for adequate supervision. On 07/08/2021 LPA conducted an unannounced visit to the facility and found the outer gate to be locked. LPA called the facility and staff (S1) opened the gate for LPA to enter. LPA spoke with S1 who stated the gate is locked because residents in the home have mental impairments which cause wandering. LPA spoke with Administrator during time of visit, who stated the facility did not have a waiver for the exterior gate to be locked. LPA requested to review resident's needs and service care plans. LPA reviewed a sample of two (2) of two (2) residents' needs and service plans. LPA did not find a plan in place to address resident wandering. Based on the information above, LPA finds the allegation to be SUBSTANTIATED, meaning the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of regulations, Title 22. Deficiencies are being cited on the attached LIC9099D. Exit interview conducted, copy of report provided. Allegation: Facility staff are locking residents in their rooms. Complaint alleged facility staff are locking residents in their bedrooms to substitute for adequate supervision. On 07/08/2021 LPA conducted an unannounced visit to the facility and found the outer gate to be locked. LPA called the facility and staff (S1) opened the gate for LPA to enter. LPA spoke with S1 who stated the gate is locked because residents in the home have mental impairments which cause wandering. LPA spoke with Administrator during time of visit, who stated the facility did not have a waiver for the exterior gate to be locked. LPA requested to review resident's needs and service care plans. LPA reviewed a sample of two (2) of two (2) residents' needs and service plans. LPA did not find a plan in place to address resident wandering. No further evidence could be provided. Based on the information above, LPA finds the allegation to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, and the findings are unsubstantiated. An exit interview was conducted. No deficiencies were cited on today’s date. Appeal rights provided. Allegation: Staff are not adequately trained. Complaint alleged staff (S2) does not have adequate training. LPA reviewed S2's training on 07/09/2021 and found S2's training was current and adequate. LPA spoke with Administrator on 07/08/2021 who stated S2 was trained, however S2 did not meet facility's standards for the position. Administrator stated S2 was not accountable, therefore S2's employment was terminated. Allegation is UNFOUNDED. Allegation: Staff are over medicating residents. LPA conducted a medication audit for a sample of two (2) of two (2) residents in care. LPA did not observe errors upon audit. On 07/08/2021, LPA interviewed two (2) of two (2) residents in care. Residents stated they receive their medications and did not have problems with getting their medications. Allegation is UNFOUNDED. Allegation: Staff are not administering medications as prescribed. LPA conducted a medication audit for a sample of two (2) of two (2) residents in care. LPA observed no errors. On 07/08/2021, LPA interviewed two (2) of two (2) residents in care. Residents stated they did not have issues with their medications. Allegation is UNFOUNDED. Allegation: Facility is malodorous. LPA visited the facility on 07/08/2021 and observed the facility to be clean and free of foul odor. LPA spoke with two (2) of two (2) residents in care who stated the facility is kept clean and does not smell. LPA spoke with staff (S1) who stated the facility is kept clean and does not have a foul smell. LPA spoke with a key witness who stated the facility did not have a foul smell during their visits. Allegation is UNFOUNDED. Due to the information above, the Department finds the allegations to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted, copy of report provided.