complaint·July 27, 2022

Interview conducted with Acting Administrator indicated that the facility has one (1) live-in staff member (S1) who sleeps at the facility at night but is on-call to assist residents with care throughout the night. LPA observed a time sheet for S1 indicating that S1 works 4 days a week from 8:00 AM to 4:30 PM. On days in which S1 is not working, staff member (S2) works from 7:00 AM to 7:00 PM. There is no time-sheets for Administrators. LPA reviewed resident records for residents R1, R2, R3, R4, R5, R6, and R7. Physician's Report (LIC 602) for R2 with a physician's signature dated 4/28/2022 indicates that R2 has a diagnosis of dementia. Preplacement Appraisal Information (LIC 603) for R2 dated 4/29/2017 indicates that R2 has "Alzheimer's dementia" and needs special observation/night supervision. Resident Appraisal (LIC 603A) for R2 dated 12/18/2018 indicates that R2 has "Alzheimer's Dementia" and needs special observation/night supervision due to confusion, forgetfulness, and wandering. Resident Appraisal (LIC 603A) for R2 dated 4/15/2022 indicates that R2 is "confused and disoriented, unable to communicate due to Dementia," and indicates both "yes" and "no" to R2 needing special observation/night supervision. Based on interviews conducted by the department 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 with Acting Administrator. A copy of this report and appeal rights were provided. Acting Administrator's signature on these forms acknowledges receipt of these documents.