complaint·March 29, 2024

(Continued from LIC9099 p.1) Staff interview and LPA observations further revealed that a sign informing the public regarding Licensing reports existed at the facility, but had been taken down at an unknown time and placed in an office, away from public view. Based on interviews, records review, and LPA observations, the preponderance of evidence has been met that alleged violation occurred and is therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Executive Director Marlen Arguero-Hernandez, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued from LIC9099 p.1) Staff interviews were also inconsistent regarding the facility's policy on moving furniture; some staff informed that moving resident furniture was against facility policy due to liability reasons. Other staff informed that this policy did not exist, and that the required furniture should have been moved. Staff interviews and records review further revealed that the staff member who moved R1's bed into the temporary room was disciplined for the action. No records were found to corroborate that a facility policy existed restricting staff from moving resident furniture. Records and interviews did not produce evidence to confirm which furniture was moved into R1's temporary room. LPA directly observed the unfurnished room in question; the lighting was ambient from the bathroom only; no ceiling light existed in the room. Outside sources interviewed did not have observations and/or were not able to recall which furniture existed in R1's temporary room during the timeframe of complaint. R1 passed away in June 2023 and was not able to be interviewed for the investigation. It was alleged that the Licensee did not provide a Resident 1 (R1) with basic laundry service. Staff interview revealed that laundry was completed according to a weekly schedule, and evening caregivers were responsible for putting resident laundry out, to be picked up by laundry staff the next morning. Staff interview further revealed that R1 had significant incontinence issues, which resulted in their clothing needing to be changed more frequently. Review of facility records corroborated staff statements that R1's personal laundry was washed each Friday by caregiving staff, and R1's linens and towels were washed on Mondays by housekeeping staff. Records also revealed that between January - March 2023, 11 additional loads of R1's laundry were washed outside of R1's regular wash day, as needed. Outside sources interviewed had not observed R1 in dirty, mismatched, or missing clothing, nor had they observed R1's closet to be void of clothing or an overflowing laundry basket. R1 passed away in June 2023 and was not able to be interviewed for the investigation. It was alleged that the Licensee did not employ a full-time activities director, as required based on capacity. Staff interviews revealed that while the activities director position was vacant during the timeframe of complaint, temporary staff were put in place to perform the duties until a permanent staff member was identified. (Continued on LIC9099-C p.3) (Continued from LIC9099-C p.2) Records review corroborated staff statements; schedules and personnel records showed that a combination of 3 staff members were assigned to the activities director position from December 2022 to April 2023. It was alleged that the Licensee did not provide a responsible person a written report of an incident which threatened a resident’s welfare within seven days. Review of Department and facility records revealed that the incident in question occurred on 6/3/23 and the responsible person was notified by staff regarding the incident via phone. Records review further revealed that the Licensee emailed the incident report to the responsible party on 6/7/23, four (4) days after the incident occurred. The evidence shows that the Licensee provided the incident report within the required timeframe. It was alleged that the Licensee did not provide a responsible person copies of resident’s general care records within two business days. Staff interview revealed that the Executive Director acknowledged the records request the day it was made and started the process. Staff interview further revealed that records requests were provided after the corporate legal team affirmed it. Staff interview, corroborated by records review, showed that the request was made by the responsible person on 6/14/23 and acknowledged by the Executive Director. Records review further showed that the records were sent to the responsible person on 6/20/23. The evidence shows that the facility started the records request immediately to produce the records, and they were provided to the responsible person. Based on interviews, direct LPA observations and records review, the investigation did not yield sufficient evidence to conclude that Licensee did not provide resident with required bedroom furniture, Licensee did not provide resident with basic laundry service, Licensee did not employ a full-time activities director, as required based on capacity, Licensee did not provide a responsible person a written report of an incident which threatened a resident’s welfare within seven days, and Licensee did not provide a responsible person copies of resident’s general care records within two business days. Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegations may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Executive Director Marlen Arguero-Hernandez , to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.