complaint·December 5, 2023

Staff interviews said that there are times when the residents accidentally take their devices with them out into the community which staff are unable to answer. A review of the facility’s activity records for the months of August 2023 and September 2023, there were five residents whose call button were over the time frame of 30 minutes. Submission of incident reports (IR) were reviewed for the months of August 2023 and September 2023. Upon review of the IR’s, there was only one incident report on file submitted to the San Diego Regional Office that reported resident sustaining an injury due to a fall, but according to the Device Activity Report, there was no call to the room. According to that IR the staff responded accordingly by contacting emergency response. In review of additional submitted reports, residents who sustained falls were taken to the hospital for further evaluation and treatment. None of the IR’s displayed major injuries due to staff untimely response of call devices. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and outside source interviews, records reviewed, and LPA observations, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Executive Director Michael Sokolowski. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Executive Director Sokolowski at the conclusion of the visit. The signature below confirms the receipt of these documents.