complaint·March 29, 2024

Based on evidence obtained, the allegation was Substantiated. The deficiency was cited in accordance with California Code of Regulations, Title 22, and listed on the LIC 9099D. A plan of correction was jointly formulated with Licensee Odborne. An exit interview was conducted with Doverte and Osborne, to whom a copy of this report, LIC 9099D, and Licensee/Appeals Rights (LIC 9058), were provided. The investigation did not yield enough evidence to prove the facility staff were not following this diet. It was alleged the Licensee violated a resident's personal rights. It was reported to the Department a resident was not allowed to have private telephone conversations and that the resident was not allowed to seek a new facility. Interviews with internal and external sources revealed conflicting statements regarding the resident’s desire to leave the facility, and the resident’s conservatorship status. An interview with the resident did not reveal any concerns with the facility not allowing the resident to relocate, nor the facility not allowing the resident to have private phone conversations. Interviews with the resident’s responsible party and the facility administrator revealed there had been concerns regarding a third party contacting the resident, encouraging the resident to relocate. Records obtained by the Department confirmed the resident had a guardian appointed prior to the resident being admitted. It was alleged the Licensee did not maintain accurate record keeping of the administration of medication. It was reported to the Department the facility did not document the administration of insulin for a resident. Interviews with a source revealed the resident in question was diabetic but was not prescribed insulin. Review of records, including medication records, and interviews of sources did not reveal any concerns regarding lack of documentation. Additionally, interviews along with the resident’s physician’s report revealed the resident had a history of refusing medication. An exit interview was conducted with Doverte and Osborne, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided.