complaint·December 3, 2024

. Regarding the allegation “Staff do not have fingerprint clearance” LPA retrieved a facility roster via Guardian Background System, and observed that Staff #1, Staff#2, and Staff#3, that were currently working at the facility all were eligibly cleared. LPA conducted a file review for Staff 1-3 and discovered that all clearance records were on file. Third allegation , Staff lock facility doors to prevent residents from leaving. Regarding the allegation “Staff lock facility doors to prevent residents from leaving” LPA conducted a walkthrough of the facility and inspected six out of six resident’s bedrooms along with resident’s doorknobs and observed that no laches or childproof locks were in place. In addition, LPA conducted an inspection on all doors along with emergency exists and witnessed that no latches or childproof locks were in place. LPA conducted interviews with residents regarding the allegation “Staff locking facility doors to prevent residents from leaving” all residents denied being locked or prevented from leaving the facility. LPA conducted interviews with staff regarding the alleged allegation, and all denied locking or preventing residents from leaving the facility. Fourth allegation , Staff insert suppositories to residents in care. Regarding the allegation” Staff insert suppositories to residents in care” LPA conducted interviews with staff and all staff denied utilizing or inserting suppositories to residents. In addition, all staff informed LPA that suppositories are not kept or stored at the facility. LPA conducted interviews with residents, and all denied having suppositories inserted by staff. LPA conducted a medication inspection and discovered that no suppositories are being stored. Fifth allegation , Staff did not complete required trainings. Regarding the allegation “Staff did not complete required trainings” LPA conducted a full staff file review and observed that training was completed LPA also observed certificates of completion to be on for all staff. Sixth allegation , Staff did not maintain resident records. Regarding the allegation “Staff did not maintain resident records” LPA conducted a file review of all resident records and discovered that all required documentation for six out of six residents were on file based on Title 22 Residential Care Facility for Elderly (RCFE). Seventh allegation , Residents are not provided proper food service. Regarding the allegation “Residents are not provided proper food service” LPA conducted an inspection on facilities food supply. During the inspection LPA discovered that the facility had adequate amount of food supply to meet resident needs. In addition, LPA observed that all food including canned goods sustained current shelf life. LPA conducted interviews with residents where five out of six residents stated that that the food is okay and have no concerns. Resident#6 stated that the breakfast that is served is good, and that Resident#6 purchases and stores their own lunch and dinner. Eighth allegation , Staff did not ensure resident’s diapering needs were met. Regarding the allegation “Staff did not ensure resident’s diapering needs were met” LPA conducted interviews with residents pertaining to the allegation resident’s diaper needs were not met. Six out of six residents denied the allegation and stated that staff completes their diaper needs and change residents on a timely manner. Ninth allegation , Staff did not provide adequate medication assistance to residents in care, Regarding the alleged allegation. LPA conducted interviews with residents and six out of six residents stated that they receive medication on a timely manner. In addition, all residents stated that medication is always given and not withheld by staff. LPA conducted a file review of residents MAR records and observed that all medication is being distributed and managed correctly by staff. Tenth allegation , Staff threatened residents in care. Regarding the allegation “Staff threatened residents in care” LPA conducted interviews with residents pertaining to the alleged allegation and six out of six residents denied being threatened or mistreated by staff. In addition, all residents denied witnessing staff threat other residents in care. LPA conducted interviews with staff regarding the allegation stated above, all staff denied threatening or mistreating residents in care. In addition, staff also denied witnessing other staff threat or mistreat residents in care. Eleventh allegation , Staff did not ensure sufficient food items were available at the facility for residents in care. Regarding the allegation stated above. LPA conducted an inspection on facilities food supply. During the inspection LPA discovered that the facility had adequate amount of food supply to meet resident needs. LPA conducted interviews with residents and six out of six residents stated that the food provided is fulfilling and have no issues with food or snack supply. Twelfth allegation , Staff yelled at residents in care. Regarding the allegation “Staff yelled at residents in care” LPA conducted interviews with residents pertaining to the allegation stated above and six out of six residents denied being yelled at by staff. In addition, all residents denied witnessing staff yell at residents in care. LPA conducted interviews with staff regarding the allegation stated above, all staff denied yelling at residents in care. In addition, staff also denied witnessing other staff yell at residents in care. Thirteenth allegation , Staff did not assist residents that sustained falls. Regarding the allegation” Staff did not assist residents that sustained falls” LPA conducted interviews with residents, and all denied staff not assisting residents with transfers. All residents also stated that caregivers are very involved with helping residents who are non-ambulatory. Furthermore, during interviews residents denied witnessing residents sustain falls and not being assisted by staff Fourteenth allegation , centrally stored medications are accessible to residents in care. Regarding the allegation “Centrally stored medications are accessible to residents in care” LPA conducted a walkthrough of the facility during the walkthrough LPA discovered a black metal cabined located across bedroom #6 that was locked and secure. LPA checked cabinet to ensure that the cabinet was locked and secured. During the inspection facility staff opened the cabinet with a key (no magnet) and demonstrated to LPA that medication cabinet remains locked and inaccessible to residents in care. Fifteenth allegation , Staff do not have a fire evacuation plan at the facility. Regarding the allegation “Staff do not have a fire evacuation plan at the facility” LPA conducted a walkthrough of the facility and observed proper fire evacuation posters posted around the facility. LPA conducted a record review and observed that the last evacuation was completed in November. LPA observed exit signs throughout the facility. In addition, staff informed LPA that the main entry door is their primary exit in case of a fire. LPA observed that five out of six bedrooms have an exit door. Sixteenth allegation , Staff do not have an infection control plan at the facility. Regarding the allegation “Staff do not have an infection control plan at the facility” LPA conducted a record review and observed that facility had an infection control plan in place that was current. In addition, LPA observed proper postings throughout the facility that indicated the preventions and the spreads of infections and illnesses. Seventeenth allegation , Staff are not following reporting requirements. Regarding the allegation “Staff are not following reporting requirements” LPA conducted interviews with staff who informed LPA that Special Incident Reports, are faxed to CCL office when pertaining to any incident involving the residents in care. Staff in formed LPA that the lates report was faxed a few days ago regarding Upland Police Department conducting a wellness check. Eighteenth allegation , Staff left residents unattended. Regarding the allegation “Staff left residents unattended” LPA conducted interviews with residents regarding the allegation stated above all six residents denied being left alone or unattended at the facility. LPA conducted interviews with regarding the alleged allegation all staff denied leaving residents in care unattended or unsupervised. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated. Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Caregiver Eladia Plenos at the end of the visit. Substantiated: A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, 87207 False Claims, from division 6, chapter, article 6, is being cited on the attached LIC 9099 D. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along with a copy of the appeal rights. to Facility Caregiver Asenath Lainez-Munoz. Third allegation, Staff did not prevent residents from engaging in inappropriate interactions. Regarding the allegation “Staff did not prevent residents from engaging in inappropriate interactions” LPA conducted a resident file review and discovered that Resident #2, Resident #3, Resident #4, and Resident #5, that were listed in the alleged allegation are not residents that have ever lived at the alleged facility. Based on the available information, LPA found the complaint allegation is Unfounded. Unfounded: A find of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted where this report was discussed, and a copy provided to Facility Caregiver Eladia Plenos.