complaint·November 8, 2024

Allegation: Due to staff neglect, resident developed a pressure injury. Based on staff interviews, and record review. Five (5) staff interviewed denied neglecting residents. Interviews revealed that if residents in care have pressure injuries, they are checked every two hours, and any concerns are reported to management, hospice, and resident family. Staff denied that residents are neglected but stated additional staff is needed. Allegation: Staff did not ensure residents’ room was clean. Based on observation, record review, and interviews with facility staff and residents. All resident’s room are cleaned regularly as indicated in the staff cleaning schedule. Allegation: Staff did not ensure residents hygiene needs were met. Based on observation, record review, and interviews with residents and facility they all deny that residents hygiene needs are not met. LPAs observed the residents showering schedule and there is no evidence to corroborate the allegation. Allegation: Staff did not ensure residents’ laundry was done timely. Based on observation, record review, and interviews with residents and facility staff. The resident’s laundry is done timely and is documented in the staff’s laundry schedule. Allegation: Due to lack of staff, medications were not administered timely. Based on record review and interviews with residents and facility staff. All resident’s medications are administered timely. There is no evidence to corroborate this allegation. During the investigation, LPA did not find evidence to corroborate the allegations. Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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, therefore the allegation is unsubstantiated at this time. An exit interview was conducted where this report, LIC9099 was discussed and provided to Executive Director Monique Del Junco. Allegation: Due to lack of supervision, resident had multiple falls resulting in injury. - Based on interview and record review, Staff indicated that there’s not enough staff working in memory care to provide sufficient supervision. LPA Serrano also interviewed Resident Care Director (RCD) Jonnathan Rios and requested the facility's staff schedule. It was observed that staff coverage on the weekends is less than during the weekdays. RCD mentioned that new staff are in training and will be ready to work once their training is complete. Based on LPAs observations and interviews and records review conducted, the preponderance of evidence standard has been met, therefore, the allegation of Staff did not safeguard residents’ personal property and Due to lack of supervision, resident had multiple falls resulting in injury are SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 6 is being cited on the attached LIC9099D. An exit interview was conducted where this report (LIC 9099), LIC9099D, and Appeal Rights were discussed and provided to Executive Director Monique Del Junco.