complaint·April 23, 2025

R1’s physician’s report dated March 12, 2025, confirmed R1 was diagnosed with Alzheimer’s Disease, had sundowning behavior, was unable to follow instructions, and required staff assistance for all activities of daily living (ADLs). R1 was unable to be used a reliable historian to aid in this investigation due to their baseline memory loss. Records review revealed that on April 3, 2025, local law enforcement conducted a visit to the facility during the night hours. Per the police report, a tour of the facility and interviews with staff and residents were conducted. Interviews with staff revealed that the facility staff had installed a lock on R1’s door and was locking R1 into their bedroom, from the outside, during the nighttime hours. Interviews with staff revealed R1’s wandering behaviors are primarily prominent during the night hours. On April 4, 2025, LPA accompanied by staff, toured the interior of the facility and inspected each bedroom. LPA observed R1’s bedroom door with a lock on the doorknob that could be locked from the outside via a key. LPA observed R1 to be unaware of their surroundings. LPA was unable to qualify R1 for interview. Based on direct LPA observations, interviews, and records reviewed, a preponderance of evidence exists to support the allegation. One deficiency is being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Head Caregiver Manny Rodriguez, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to. Interviews with residents did not reveal any concerns with the staff not providing care while on duty nor did the interviews reveal that resident needs were not being met. Interviews with outside sources revealed that there have been consistently at least two staff members at the facility providing care and supervision. Interviews with outside sources did not reveal the observation of staff sleeping while on duty. Interviews with residents, staff, and outside sources did not reveal that staff members were asleep while they should have been on providing care and supervision. The records reviewed by LPA did not reveal a specified staff ratio requirement for one-on-one continuous care for any residents nor did it reveal a need for additional overnight supervision. Based on interviews and record review, the investigation did not yield a preponderance of evidence to conclude that the facility staff were sleeping while on duty . Based on the foregoing, the allegation is unsubstantiated. This finding means that although the allegation 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 Head Caregiver Manny Rodriguez , to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.