Complaint·November 10, 2021

LPA reviewed copies of documents received for R6, LPA reviewed interview notes held with residents and staff conducted on prior visit date 09/15/2021. LPA reviewed phone interview notes conducted on 10/19/2021 with Administrator. LPA inspected 3-bathroom showers at the facility on initial investigation date 09/15/2021. LPA conducted interviews with the administrator 3 out of 6 staff and 4 out of 5 residents. S4 and S5 never returned phone calls from LPA placed on 10/19/2021. LPA reviewed interview notes from Admin, S1, S2 and S3. LPA reviewed interview notes from R1, R2, R3 and R4. LPA reviewed copy of SIR for R6 regarding a reported fall in the bathroom dated 08/05/2021. LPA reviewed copies of daily care notes for R6, LPA reviewed copy of LIC 602 for R6, LPA reviewed copy of MAR for R6 for month of August. LPA inspected bathrooms at facility and observed that none of the showers have safety bars inside the showers that were reported as being broken. LPA reviewed copy of appraisal needs service plan for R6. Continued on LIC 9099C... LPA interviewed POA for R6. POA could not provide dates for when alleged falls occurred. LPA learned W1 who is the cousin of POA frequently visited R6. LPA attempted to contact W1 by telephone but never received a call back. LPA reviewed copy of text message transcripts between S3 and POA, LPA learned that the POA did not provide S3 with all of the prescription changes for R6. LPA was not able to establish a timeline for when alleged falls occurred. LPA learned that S1 started working at the facility as of 08/20/2021 and the prior staff who was working with R6 is no longer employed by the care home and did not return any phone calls to LPA. Based upon interviews conducted and documentation reviewed LPA is not able to substantiate findings for the following complaint allegations. 1) Staff did not assist resident with medication as needed. LPA found no missed medications on copy of MAR for R6. 2) Resident was not accorded dignity in personal relationships with staff. Based on interviews with staff and residents, LPA could not determine resident was mistreated. 3) Facility is in disrepair. LPA did not find showers having broken safety bars. There is not substantial evidence to support or disprove that the alleged violations occurred. Due to the preponderance of evidence standard not being met by the department standard. There is no physical evidence to support the validity of the allegations as well as witness statements; LPA has deemed the complaint findings as UNSUBSTANTIATED. Although the allegations may have happened and/or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted with back up administrator Diana Garcia. A copy of this report was left with the facility upon exit. The preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. The following deficiency was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. Exit interview was conducted with Back up Administrator Bianca Castro. Copy of the report was left with the facility upon exit.