Complaint·February 22, 2023

On 2/7/2023 LPA Ivey Canady interviewed S1 regarding the care services provided by the facility to R1. S1 stated the primary caregiver for R1 was S2. On 2/7/2023 LPA Ivey Canady interviewed S2 regarding the care provided by the facility and S2 purported not to be in the facility during the 3-4 days that R1 was at the facility, and purported not to be active in R1's care. According to the interview with S2, S2 was also away at a doctor's appointment when emergency personnel were called to the facility regarding R1. On 2/7/2023 S1 gave testimony that most of the calls received from R1's family regarding the status of R1, had to be rerouted back to the facility because S1 was not present at the facility. According to witness statements, S3 told R1's family that R1 had been fed a spaghetti dinner. However, based on interviews from S1, R1 had begun to decline and remained unconscious from the beginning of R1's arrival to the facility. Furthermore, S1 stated S2 had given R1 the spaghetti dinner, however testimony from S2 is that S2 was never in the presence of R1. Therefore, the allegations Staff did not meet residents’ needs is Substantiated. Based on LPAs observations and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. On 8/12/2022 LPA Ivey Canady interviewed S1 regarding the status of R1's personal belongings. According to the interview with S1, the caregivers at the facility take out all belongings and annotate belongings on official LIC form. LPA requested copy of form. LPA did not receive a copy of the form. Based on interview with S1, the beginning of the interview with S1, there is a 2 day wait to put away belongings. Further along in the same interview, S1 made a correction and said belongings are put away immediately. On 2/7/2023, LPA requested the status of R1's left over personal belongings. S1 stated those particular belongings were never at the facility. However, according to interviews with witnesses, the belongings in question were left at the facility when R1 was taken by ambulance to the hospital. Based on interviews with S1, R1 had been fed particular meals. However, R1 would have not been able to be fed those particular meals without belongings that S1 stated was never at the facility. Therefore the allegation Staff did not safeguard resident's personal belongings is Substantiated. Based on LPAs observations and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Cont on 9099-C Page 2 of 3 Exit interview held, report given to Administrator On 2/7/2023 LPA Jamie Ivey Canady interviewed Staff 1 (S1) regarding current allegations. According to interview with S1, refund to R1's family was submitted and processed on 9/30/2022. According to interview with witness several attempts were made to secure a refund from the facility after the death of R1. Based on record review, refund was not made within 5 business days of R1 death as in accordance with facility admission agreement signed on 7/9/2022. Therefore, the allegation Staff denied to provide resident's authorized representative with a refund is Substantiated Based on LPAs observations and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview with Administrator. Appeal rights and report given. On 1/20/2023 Licensing Program Analyst (LPA) Jamie Ivey Canady interviewed R1 family witness regarding current allegations. On 2/7/2023 LPA Ivey Canady interviewed S1 regarding current allegations. According to interviews, there were many calls regarding the welfare of R1. During the calls the status of R1 was consistently asked. Based on interviews, many calls were placed to facility licensee cell number. According to interviews, there were times the phone calls to the cell phone were routed to the facility land line to get a real time status of the condition of R1. According to interviews with witness and S1, the question to speak directly to R1 was not asked. Therefore, the allegation Staff denied resident phone calls is Unsubstantiated. An unsubstantiated finding means 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, therefore the allegation is UNSUBSTANTIATED.