complaint·November 30, 2023

During the course of the investigation, Staff One (S1) could not be interviewed. Staff interviews revealed, the facility has a policy to observe and document resident’s whereabouts every 30 minutes. Staff are required to submit a Thirty Minute Log which includes the room number of every resident they are assigned to. The staff are required to document where in the facility the resident is located on this log, when they make their observation. S1 was assigned to supervise R1 on 04/24/2020. A review of the Thirty Minute Log, which included R1’s room number, dated 04/24/2020, revealed, R1 was seen in the TV room, every 30 minutes, starting at 12:30pm until 2:30pm. One staff interview revealed, S1 made a statement that they had last seen R1 at 1:45pm when they provided a service to R1. Staff interviews contradicted the Thirty Minute Log filed by S1. S1 was last observed at 1pm, when they left the unit they were assigned, to participate in a staff celebration and was not seen returning to the unit until 2pm. Staff interviews did not reveal the last time R1 was observed. Staff interview revealed that R1 had not been seen during lunch, which is between 11am and 11:30am. The investigation shows R1 was outside for an unspecified amount of time. Discharge Summary from the hospital, dated 04/28/2020, revealed R1 was diagnosed with Second Degree Sunburn. This allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An immediate civil penalty of $500 is being assessed during today’s visit. In accordance with H&S Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department. An exit interview was conducted where this report, LIC9099D, LIC 811, LIC421IM, and appeal rights were discussed and provided to the Executive Director.