Complaint·November 7, 2024

Additionally, LPA Lee interviewed 5 facility staff members, all of whom denied the allegations of document falsification. Based on the interviews and evidence gathered during the investigation, LPA Lee was unable to corroborate the allegations. It was alleged that licensee does not ensure that residents are provided with activities while in care. The investigation included observations, a review of records, and interviews with both facility staff and residents. On 10/07/2024, LPA Lee observed a facility staff member leading an exercise activity in the common area with the residents. A review of the facility’s records confirmed the presence of a monthly activity calendar, detailing daily events. Additionally, six out of seven residents interviewed denied the allegations, confirming that activities are provided regularly. They also stated that they are aware of the activity calendar’s location and were able to describe activities such as bingo, news discussions, movie nights, exercise sessions, and singing. LPA Lee also interviewed 5 facility staff members, all of whom denied the allegations and reported that there are three activities per day. Based on the interviews and evidence gathered during the investigation, LPA Lee was unable to corroborate the allegations. 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 violation(s)occurred. Along with facility staff, LPA compared and reviewed medication count to medication administration record and found that resident 1 (R1)’s 14 pills of Atorvastatin were not accounted for however were signed off by facility staff as administered. The Med-Tech staff acknowledged the discrepancy at the time of audit and explained that the missing 14 pills may have not been accounted for when R1 was admitted to the facility 07/15/2024. Additionally, LPA Lee interviewed 3 out of 7 residents, who reported that they had not received their medications from the Med-Tech staff as prescribed. Based on the interviews and evidence gathered during the investigation it was found that the facility staff are mismanaging and not administering medication as prescribed to residents in care. An allegation was made that the facility is odiferous. The investigation included observations and interviews with residents and staff. On 08/19/2024, LPA Lee, Ombudsman Suhair, Administrator Hong Trinh, and Licensee Pak Wu toured the Terrance Hall. It was observed a strong urine odor in resident room #24. Additionally, a mild urine odor was noted in resident room # 27. Interviews with 4 out of 7 residents revealed that the upstairs area of the Terrace building does has a strong urine odor. Based on the observations and resident interviews, LPA Lee was able to corroborate the allegation. As a result, this allegation is 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 Tasha and Melissa and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.