Inspector’s narrative
What the inspector wrote
Allegation: Staff did not ensure resident records were properly maintained
It was alleged that staff did not ensure resident records were properly maintained. This investigation is based on observation of resident records. On 3/19/2025, LPA Lee conducted a facility visit and upon observation of 4 out of 4 resident files, and 2 of them were found to be incomplete. Both R3 and R4 had an LIC 625 Needs and Service Plan form in their files, but the document was not signed by both the administrator and the resident or their responsible party, and the form was blank. It was also observed that R3’s LIC 602 Physician’s Report was incorrectly placed in R1’s file. Resident records were observed not in compliance with Title 22 regulations Resident Records 87506(a). As resident records were observed not organized, and resident records were included in other resident files.
As a result, these allegations are
SUBSTANTIATED
. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Una Waqalala and a copy of this report LIC 9099, LIC 9099-C, LIC 9099-D was provided, along with Appeal Rights and the LIC 811, the Confidential Names List.
LPA Lee observed two designated areas for activities: one in the common area inside the TV stand and another in the dining area. Both areas were equipped with a variety of activities, including board games, puzzles, card games, books, painting supplies, markers, and crayons. On 5/06/2025 LPA Hughes and Lee conducted a follow-up visit to the facility, upon R5- was observed outside in the courtyard, R3- In bedroom watching television, R4- In bedroom in recliner sleeping, R2- In bedroom with a tablet watching television, R1 in bedroom sleeping. As stated in the facility program design, activities for residents include but are not limited to, resident’s assisting with meal preparation and grocery shopping, residents are also encouraged to socialize by offering opportunities to read aloud, participate in tea and office chats, ice cream socials and birthday parties. Watering plants, dancing, exercising and listening to music. On 5/28/2025 LPA Hughes, conducted interviews with 4 out of 4 residents, and concluded that no activities were being provided at the facility. Resident activites were observed as not in compliance with Title 22 regulations section 87219(a) as resident activities in the facility are not being planned or provided for residents in care.
Allegation: Staff did not ensure a first aid kit was maintained at the facility
It was alleged that staff did not ensure a first aid kit was maintained at the facility. This investigation is based on observation. On 3/19/2025, LPA Lee conducted a facility visit and upon observation a first aid kit was in the facility; however, the first aid manual was missing. This first aid kit was observed not in compliance with Title 22 regulations on Incidental Medical and Dental Care 87465(a)(8). As a first aid manual is a required component to be included with a first aid kit.
Continuation 9099-C
Allegation:
Hazards were made available to residents in care
It was alleged that hazards were made available to residents in care. This investigation consisted of facility observations, and interviews. On 3/19/2025 LPA Lee conducted a tour of the facility; no hazards were observed inside the building or in the courtyard. On 5/6/2025 LPA Hughes and Lee toured the facility for a follow-up visit and no hazards were made available to residents in care. Additionally, a phone interview with the reporting party (RP) revealed that no hazards were made available to residents in care, stating that this allegation was incorrect for this facility. Based on observation this allegation could not be corroborated with any supporting evidence.
Allegation: Staff obstructed facility emergency exits
It was alleged that staff obstructed facility emergency exits. This investigation consisted of facility observations and interviews. On 3/19/2025 LPA Lee conducted a tour of the facility; the emergency exit was not observed obstructed. However, it was observed that the emergency exit gates are not self-latching. On 5/06/2025 LPA Hughes and Lee conducted a follow-up facility visit; emergency exit located in the garage was not observed to be obstructed. Additionally, on 5/28/2025 LPA Hughes interviewed 4 out of 5 residents who did not observe any emergency exits being obstructed. 1 facility staff also denied observing facility emergency exits being obstructed. Based on observation, and interviews no corroborating evidence was identified upon examination of the allegation.
Allegation: Staff did not ensure sufficient healthy food items were made available at the facility for residents in care
It was alleged that staff did not ensure sufficient healthy food items were made available at the facility for residents in care. This investigation consisted of facility observation. On 3/19/2025 LPA Lee conducted a tour of the facility, upon observation the 2- day perishable food supply contained sufficient healthy food items made available to residents in care. On 5/28/2025 LPA Hughes, interviewed 4 out of 5 residents who are satisfied with the food being served in the facility. Based on observation, no corroborating evidence was identified upon examination of the allegation.
Continuation 9099-C
Allegation: Facility in disrepair
It was alleged that; the facility is in despair, lights were inoperable. This investigation consisted of facility observations and interview. On 3/19/2025 LPA Lee conducted a tour of the facility; upon observation the facility was observed in good repair. On 5/6/2025 LPA Hughes and Lee conducted a follow-up facility visit, and observed the facilities resident bathroom, which was observed to be in good repair, lighting within the facility was observed operable and in good repair. Additionally, on 5/28/2025, LPA Hughes interviewed 4 out of 5 residents who had no concerns with the facility being in disrepair. Based on observation, and interviews conducted, no corroborating evidence was identified upon examination of the allegation.
The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be
UNSUBSTANTIATED
. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.
Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited. An Exit interview was conducted with XXXXX and a copy of this report LIC 9099, LIC 9099-C, LIC 9099-A was provided, along with Appeal Rights and the LIC 811, the Confidential Names List.
