Inspector’s narrative
What the inspector wrote
R6 needed one person assistance transferring, according to the appraisal. R6 did not need special overnight supervision, according to the appraisal. The appraisal is signed and dated by R6. A needs and services plan for R6 dated 12/3/24 indicated R6 needed assistance with transfers to and from their wheelchair and assistance with their ADLs. However, no mention of turning or repositioning was made in R6's needs and services plan. The plan was signed by R6.
LPA Moleski reviewed medical records from a hospital visit for R6 dated 12/18/24. R6 was diagnosed with wounds to the left heel and right ankle, which were not staged. The wound on R6's left heel was described as a "deep pressure wound. Soft and boggy to touch. Deep purple in color. No open skin noted." The wound on R6's right heel was described as a "small wound. No surrounding erythema, no drainage." Older medical paperwork dated 11/13/24 also diagnosed R6 with bilateral foot wounds, similarly unstaged.
In an interview, R6 said they were at least partially able to reposition themselves, and said that they sometimes receive staff assistance with transferring to and from bed. R6 said they are sometimes able to transfer on their own. R6 said they receive care when they request assistance, and said that if they require nighttime assistance, they can call for the live-in caregiver (S1) and they will respond. On 3/4/25, R6 was observed to have small scabs or blisters on their heel. The wound was not open, but was difficult to assess due to the scabbing. R1 said that the wound was assessed by medical professionals on 12/18/24, who said that they were "not even stage one," according to R1.
Interviews with staff suggest that R1 was provided with barrier cream treatments and attempts were made to elevate R1's feet at night in order to reduce pressure.
In an interview, a resident (R1) alleged that care is provided at this facility only from 7 a.m. to 7 p.m. R1 alleged that staff members have refused to provide care and assistance to them, including refusing to empty their urinal containers. R1 also alleged that they were threatened by the licensee.
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All other residents interviewed reported that they receive care at any time when they need assistance. S1, the live-in caregiver, said they will get up and respond to any resident if they need assistance. No concerns regarding care were voiced by other residents who were interviewed. Other residents interviewed did not voice specific concerns regarding the conduct of the licensee. However, R5 said they overheard an incident wherein the licensee told R1 something to the effect of "get out." R5 said it was in a "loud voice," but did not describe it as yelling. R5 said that the licensee has a naturally "big voice." R3 said they also overheard an incident wherein the licensee was discussing complaints made against staff with R1. R3 said the licensee may have been yelling, but they were in their room at the time and were not present to witness the interaction. In an interview, Jack said there was an occasion on or around Nov. 27, 2024, in which R1 was "belligerent." Jack said that he told R1 they were disturbing other residents and would have to leave if they continued. R1 said that on this date, the licensee had told them to pack their belongings and leave. Other residents and staff interviewed could not verify that this incident occurred as described by R1.
The department has determined the following as it relates to the allegations that
staff are not repositioning a resident, resulting in a pressure injury, that the licensee threatened a resident, and that staff are not providing assistance with activities of daily living.
Based on interviews, observation, and record review, the above allegations are UNSUBSTANTIATED, which 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.
No deficiencies were cited regarding these allegations. An exit interview was held and a copy of this report was left with Jack.
However, no provisions are made for eviction due to reduced needs. Additionally, eviction due to changing needs also requires a reappraisal to document the newly identified needs. No such reappraisal were present in R1's file. The notice did not contain a statement regarding unlawful detainers, as required by HSC Section 1569.683(a)(4). This initial eviction notice was rescinded after an advisement by LPA Kimberly Viarella.
The second notice, dated Jan. 11, 2025, indicated that R1 was being evicted due to non-payment of rent. According to the notice, The rent was due on Jan. 1, but was not received as of the date of the notice. The notice did not contain a statement regarding unlawful detainers, as required by HSC Section 1569.683(a)(4). In an interview, Jack said that this second notice was given in error, as payment arrangements had already been made by the agency paying for R1's stay. However, Jack said, he was not aware of this at the time. According to Jack, the notice was later rescinded after he was made aware of the updated payment arrangements.
Neither of the notices served were legal, based on 22 CCR and HSC requirements. However, this does not preclude the licensee from serving new, lawful eviction notices to R1 in the future. If the licensee chooses to pursue eviction, they agree to send a draft notice with all relevant supporting documents to CCLD for review.
In an interview, R1 said that a staff member (S6) locked them out of the facility on one occasion, and they had be let in by another resident. R1 said the incident occurred at the door leading into the backyard from the kitchen.
In an interview, another resident (R6) said they had witnessed the incident as described above. R6 said the staff member "just wouldn't open the door" for R1. R6 said it seemed like the staff member didn't like R1. R6 said the staff member stared at R1 and laughed. R6 has no cognitive deficits or memory impairments, according to their medical records. In an interview, S6 said that they had locked the back door around 7 p.m., the end of their shift, while R1 was outside. S6 said R1 knew what time they typically locked up. S6 said that R1 "couldn't have been locked out" because there were multiple alternative entrances to the facility, such as the front door or R1's exterior bedroom door. S6 said they did not hear R1 calling to be let in.
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Other residents and staff members interviewed did not report any rude behavior from staff members. In an interview, Jack said there was an occasion on or around Nov. 27, 2024, in which R1 was "belligerent." Jack said that he told R1 they were disturbing other residents and would have to leave if they continued. R1 said that on this date, the licensee had told them to pack their belongings and leave. Other residents and staff interviewed could not verify that this incident occurred as described by R1.
The department has determined the following as it relates to the allegation of illegal eviction and the allegation that a resident was not treated respectfully by staff:
Based on interviews and record review, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met.
This facility is being cited per 22 CCR Section 87224(a) and 87468.1(a)(1)
. An exit interview was held with Jack. Appeal rights and a copy of this report were left with Jack.
