complaint·May 29, 2025

LPA arrived at the facility on March 6, 2025 to open complaint. LPA was refused entry of the home by S1 after LPA provided proper identification and stated the purpose of their visit. LPA was eventually provided entry of home by House Manager on March 6, 2025. LPA provided technical support regarding inspection authority during visit. Interviews wit h staff members S1, S2, and Licensee, Jeanina Lita, indicated that visiting hours at the facility are from 10:00 AM to 4:00 PM. Interview with Licensee indicated that, if the visitor is not someone the facility staff know, they may consult with the family to confirm whether the resident knows the visitor before facilitating visitation. LPA discussed with LIcensee PIN 25-04-ASC, which states "Third parties, such as court-appointed conservators and agents under powers of attorney generally may not curtail a resident’s right to have visitors, confidential telephone calls, and personal mail unless they have explicit authority to do so." Licensee stated that, if a visitor arrives at the facility outside of visiting hours, S1 will call Licensee and inform the visitor of visiting hours. Licensee stated that the facility has accommodated visitors outside of visiting hours. Interview with S1 indicated that that S1 will not allow visitors inside the facility if they arrive on the premises outside of visiting hours. S1 stated that they will answer the door outside of visiting hours, but they will not let the individual inside the facility. S1 stated that they "are willing" to provide Licensee's phone number to visitors if they arrive outside of visiting hours. LPA reviewed Visitor Policy Addendum that is signed by residents as part of their Admission Agreement, which states "We want our residents to have visitors, but also take everyone's safety and comfort seriously- As such, our visiting hours are from 10:00 AM to 4:00 PM by appointment only. We require 24-hour notice for a visitation along with approval by our administrative staff. We reserve the right to deny a visitation if prior scheduling was not made. We also reserve the right to deny any appointment if it interferes with prescheduled activities of other residents. A second option for visitation is to have a set recurring time for visitation, this allows staff to be aware of visitation and plan facility activities accordingly. Failure to comply by this house rule will lead to termination of lease agreement." ** Report continued on 9099-C ** Based on LPA's observations, interviews conducted, and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents. Multiple interviews with R1 indicated that they feel that their care needs are being met at the facility and they have no concerns regarding the facility. R1 stated that they are treated well by facility staff. LPA observed R1 during multiple visits, including March 6, 2025, April 9, 2025, and May 28, 2025, and observed that R1 was clean and receiving care. Interview with Witness (W1) indicated that R1 receives good assistance with care. W1 stated that R1 is well taken care of, including hygiene assistance. Interviews with multiple representatives of R1's hospice agency indicated that they had no concerns regarding hygiene assistance provided by facility staff for R1. Interviews with Licensee and staff members S1 and S2 indicated that they have never witnessed a resident in need of showering or incontinence care at the facility and not receiving assistance from care staff. Interview with resident (R2) indicated that they feel that their care needs are being met at the facility and they're treated well by facility staff. R2 stated that staff do a good job providing care and providing hygiene assistance. Interview with resident (R3) indicated that they are doing "OK." Allegation: Staff neglect resulted in a resident sustaining a pressure injury. Interview with R1 indicated that they have a couple of pressure sores on their "behind." Interviews with Licensee, S1, and S2 indicated that R1's pressure injuries are managed by nurses from hospice agency. Licensee and S2 stated that R1 was receiving Home Health services prior to admission to Hospice who were providing assistance with R1's wounds. Licensee and S2 stated that, since R1 was admitted to the facility, R1 has either been receiving services from Home Health or Hospice. Interviews with W1 and multiple representatives of R1's hospice agency indicated that they have not observed any neglect from facility care staff with assistance regarding R1's pressure injuries. Interview with Hospice representative indicated that R1's pressure injuries are managed by R1's hospice agency. ** Report continued on 9099-C ** Hospice representative indicated that R1 has pressure injuries on their right great toe that is half a centimeter by half a centimeter and stage 2, on their left toe that is half a centimeter by half a centimeter and stage 2, and the plantar area of the left foot that is stage 2 and improving. Hospice representative stated that pressure injuries require dressing two (2) to three (3) times a week. Hospice representative stated that R1 has a stage 2 wound on their buttocks that is "off and on." Hospice representative stated that wound on buttocks is currently healed and a little red. Hospice representative stated that repositioning would assist with wound on buttocks but R1 often does no comply with repositioning. Hospice representative stated that R1 has purple vascular disease as their primary diagnosis along with diabetes and a history of osteomyelitis. Hospice representative stated that R1 has had to have toes amputated on both feet. Hospice representative stated that R1 has neuropathy in their legs and doesn't have good sensation in feet. Hospice representative stated that facility attempted to use a hoyer lift for R1 but R1 could not tolerate sitting up because of dizziness and hypertension. Hospice representative stated that R1 didn't want to get up anymore because it was uncomfortable and doesn't want to use the hoyer lift. Hospice representative stated that R1 was admitted to hospice with more wounds than present. Hospice representative stated that, when admitted on October 21, 2024, R1 had pressure wounds to both calves, with right calf being stage 2, as well as left buttocks. Hospice representative stated that previous wounds have healed since R1 was admitted to hospice. Hospice representative stated there is no evidence of previous pressure wounds. LPA reviewed R1's hospice records. LPA observed that information obtained from R1's hospice records coincide with statement provided to LPA by Hospice representative. Allegation: Staff did not ensure resident’s room was adequately cleaned. Relevant party reported to the Department that they observed R1's room to be unclean. Interview with R1 indicated that they feel that their room is clean and staff are good about cleaning at the facility. LPA observed R1's room during multiple visits, including March 6, 2025, April 9, 2025, and May 28, 2025, and did not observe R1's room to be unclean or malodorous. ** Report continued on 9099-C ** Interviews with Licensee, S1, S2, R2, W1, and multiple representatives of R1's hospice agency indicated that they have never witnessed anywhere in the facility be unclean or in disrepair. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means 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. Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.