Complaint·September 17, 2024

...continued from 9099 LPA did not observe a time where staff could be made available to conduct an individualized activity with a resident. The only activity that was observed was staff turning on the television for residents to watch a show or movie or playing music on the television. According to an interview with S1, S1 stated the residents do not like the activity schedule and it has to be personal to each person. S1 stated they do activities. According to an interview with Administrator Beatrice, the facility does activities such as bingo days, music, or take them out to an outing. Administrator Beatrice stated that a staff member that used to work at the facility was the main person to do activities but that staff left earlier in the year. Facility floor is a tripping hazard On 06/13/2024, LPA Valerio observed the facility. The facility has a fire door located in between the living room and the back of the house where the resident rooms are located. The fire door is raised a few inches from the floor. On one side of the door way, there is a door threshold that acts as a ramp so residents can move from the resident rooms to the living area. However, if a resident where to go from the living room to the resident room area, a door threshold ramp is not present. During this visit, LPA Valerio observed a resident in a wheelchair attempting to go back to the bedroom. The resident was unsuccessful because the resident was unable to move the wheelchair across the door way. According to Administrator Beatrice, the fire marshal required the fire door to be installed as such in order to be granted a fire clearance. According to review of Regional office visit on 06/13/2023, the facility was required to install two thresholds on the fire door. Prior to receiving licensure, the deficiency was correct. However, based on LPA Valerio's observation there is only one door threshold instead of two. Continues on LIC 9099- C, page 3... ...continued from LIC 9099 - C, Page 2 Facility shower is in disrepair LPA Valerio observed the facility on 06/13/2024. The facility shower located bedroom 3 was observed to be in disrepair. The ramp leading in to the shower had tiles that were sunk into the floor and covered by a plastic shower skid matt. According to Administrator Beatrice, residents do not use the shower and it was in process of getting fixed. The facility has one other bathroom residents use to shower with staff assistance.  On 07/02/2024, LPA Valerio observed the facility shower to be in process of getting fixed. Residents were able to use the toilet but were restricted access to the shower until it was repaired. As of today's date, 09/17/2024, the shower has been fixed by the licensee. Facility records are not available and maintained During LPA's visit on 06/13/2024, Administrator Beatrice admitted that the files were not complete; however, she had the documents on her phone. Administrator Beatrice stated that residents got into the facility files and took all the papers out of the binder. LPA observed a tub full of paperwork for resident files and staff files.  Administrator Beatrice was not able to provide LPA copies of staff or resident files until 07/02/2024. Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided.  An exit interview was conducted, and a copy of the report was left at the facility. Insufficient staff to meet the needs of the residents On 06/13/2024, Resident 1 (R1) was observed playing with a trash can in a bathroom, climbing on a bed in another resident's room, aimlessly walking around the facility , and trying to exit the exit door to the backyard. During this time, S1 was observed doing the facility laundry and placing clean bedsheets on resident bedrooms. On 08/29/2024, LPA Valerio waited outside the facility for 10 minutes before staff answered the door. According to S1, S1 was cleaning a resident room and could not answer the door. Residents were observed sitting at the dining table and waved to LPA. LPA Valerio observed S1 assisting R1 with a shower. While this was happening, two residents were finishing their breakfast, one was in their room watching television, and another was sleeping. The Administrator and S2 arrived to the facility to meet with LPA; however, if they were not present, S1 would have pre-occupied for 15-20 minutes and unable to assist any other resident in care. According to Administrator Beatrice, the facility has enough staff. Beatrice states she is always there and goes back and forth between the Elk Grove Facility and Galt Facility. Staff 2 (S2) comes during the evening after S1 has completed the shift. According to an interview with S1, S1 feels that S1 can take care of all the residents and all duties of the facility. Due to cognitive impairment of the residents, LPA was only able to successfully interview Resident 2 (R2). R2 stated that it takes about 5 minutes for staff to respond to calls. R2 does not have any concerns of the facility and stated staff help R2. Licensee allows non-fingerprinted staff to assist residents It was reported to the Regional Office that the facility had an employee who is not cleared to work in the facility. LPA Valerio observed the facility on 06/13/2024, 07/02/2024, 07/23/2024, and 08/29/2024. LPA observed all staff present in the facility to have a finger print clearance and associated to the facility. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was left at the facility.