complaint·June 2, 2023

Interviews revealed that during these visits, F1 would give R1 food that was a choking risk and would say things that would agitate R1. Interviews revealed that R1's responsible party did not want F1 to visit R1 at the facility and asked facility staff to deny F1 visitation. Interviews revealed that the Executive Director attempted to educate F1 regarding R1's dietary needs and agitation. Interviews revealed that in April 2023, F1 and their spouse visited R1 at the facility, became upset and started yelling at staff, and asked to leave by staff after verbally threatening facility staff. Interviews revealed that following the incident in April 2023, facility staff denied F1 visitation on at least one occasion. Interviews revealed that there is not a current restraining order or legal document denying F1 the ability to visit with R1. The Department has investigated the above-mentioned allegation and based on interviews and record review, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page. An exit interview was conducted with Executive Director Beebee Smith via phone and Program Specialist Jessica Flores, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy. Interviews revealed that residents and their families were asked about the resident’s food preferences when they moved in, and the resident’s physician determined any meal modifications. If a resident did not like a certain food, they would inform staff who would pass the information to kitchen staff to make changes to their preferred food list. Interviews revealed that there were options for residents during each mealtime if they did not like a certain food item. Interviews revealed that if a resident’s meal preferences did not meet the prescribed meal modifications, staff would work with the resident, their family, and their physician to come to an agreement on meal modifications that met the resident’s preferences. Interviews revealed that R1 had a meal preference that differed from their prescribed meal modification and would refuse to eat those meals. Interviews revealed that staff consulted R1’s responsible parties and R1’s physician to modify R1’s diet to ensure R1 ate the meals. Interviews revealed that R1’s responsible parties were aware of the modification to R1’s diet and they assisted R1 with eating during mealtimes almost every day. Interviews revealed that there were a few residents who would refuse medication occasionally and staff were instructed to ask the resident to take their medication at least three times before notifying the nurse on staff who would attempt an additional time before noting medication refusal. Interviews revealed that if the resident had a habit of refusing medication on a regular basis, that resident’s responsible party and physician were notified. Interviews revealed that R1 would refuse medications more frequently when R1 first moved to the facility. Interviews revealed that whenever R1 would refuse medications, staff would contact R1’s responsible parties to come to the facility to persuade R1 to take the medications. Staff were informed to be direct with R1 and explain the medications to R1 which decreased the rate of R1 refusing medications. Interviews did not reveal any instances of R1, or any other residents being forced to take medications. The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with Executive Director Beebee Smith via phone and Program Specialist Jessica Flores, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.