complaint·April 4, 2025

(Continued on 9099-C) ***This is an amended report** Staff was able to produce limited resident files upon CCLD’s request on October 24, 2024. The Licensee replied that they had destroyed most of the six resident records requested by CCLD. The licensee is required to maintain a resident's file for three (3) years after their move-out (which occurred in July of 2021). Regarding the allegation that the facility staff are sleeping at night.   Staff interviews did reveal staff would occasionally sleep at night in the common room; however,  Staff 1 (S1) indicated when on duty, they would wake up every 2-3 hours to meet incontinence needs and check on residents. The S1 interview revealed that on more than one occasion, they would sleep at the house and wake to find Staff #2 (S2) asleep during the night shift, and attempt to wake S2 many times unsuccessfully. Outside source interviews reveal they have witnessed (S2)  sleeping in a chair while on shift.  According to the record review, there was at least one resident with a diagnosis of dementia at the facility. According to Interviews with staff, there was at least one resident with a diagnosis of dementia and wandering behavior. Therefore, there should be at least one night staff person awake and on duty to supervise. It was also alleged that the Licensee did not follow universal precautions.  CCLD interviews conducted with staff on July 27, 2021, reveal there were times that staff had to retrain on universal precautions. Staff interviews also revealed that all staff believed that staff did not have to wear masks because everyone was vaccinated. Additionally, staff revealed that no symptom screening was conducted during a period of approximately two months (June and July 2021), and some staff members did not wear masks for about a week or two during the same time period.  An outside source also confirms that in the month of July 2021, the licensee's staff's universal precautions were not followed.  Interviews conducted on October 24, 2024, reveal that staff were not able to recall following specific universal protocol precautions. Additionally, staff training logs for the Summer of 2021 could not be located. Based on relevant interviews and records review, the preponderance of evidence has been met that the alleged violation occurred and is therefore substantiated. Deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC9099-D pages ). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Licensee Arcelao, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. Care Giver Teresita Duclayan signature below confirms receipt of these documents.