complaint·August 2, 2023

(Continued from LIC9099) LPA observed the facility furniture to be the same and/or similar in nature to the furniture photos and videos on the website. Records review of food menus and activities showed that residents are being offered variety and quality in both categories and within the requirements of Title 22 regulations. Staff interview revealed that while residents are offered the calendared activities, they will decline to participate at times or ask for a different activity. Records review and outside sources interviewed confirmed that staff assist residents with required therapies. Regarding the second allegation, "Licensee did not ensure the food provided was of good quality", it was alleged that the Licensee did not provide a variety of protein and offered low amounts of vegetables and fruit. Staff interview revealed that residents are provided nutritional meals 3 times per day, with snacks. Interview revealed that at times the food offerings are adjusted based on what is available at the facility, but the meal service is not disrupted. Residents can request a different food option if they are not interested in what is offered. Outside source interview revealed no concerns regarding food service at the facility, and that residents enjoy the meals. Records review of the food menu showed the food options to meet the dietary requirements of Title 22. Regarding the third allegation, "Licensee did not ensure the facility was clean", Staff interview revealed that staff are responsible for daily cleaning tasks during their shifts. Cleaning tasks include sweeping and mopping, cleaning bathrooms, sanitizing counters and tables, and resident laundry. Deep cleaning tasks such as cleaning window blinds are completed every 1-2 months. Outside source interview revealed that the facility is clean and organized. Outside sources did not have concerns regarding the cleanliness of the facility. On two unannounced facility visits LPA directly observed the facility to be clean, without obstructions or hazards, and no odors that would indicate unsanitary conditions. (Continued on LIC9099-C) (Continued from LIC9099-C) Regarding the fourth allegation, "Administrator not on the premises a sufficient number of hours", Staff interview revealed that the Administrator is on the premises between 15-30 minutes each week. Title 22 87405(a) states, "…The administrator ... shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration". Staff and outside interviews revealed the facility House Manager to be the designated staff qualified to complete the necessary administration tasks at the facility. Interview revealed the House Manager to be present at the facility full time and also available and responsive via phone while not at the facility. On two unannounced facility visits LPA directly observed the House Manager present at the facility; House Manager was observed to have intimate knowledge of the facility, resident care, and staff management situations. During these facility visits the House Manager answered all questions regarding how the facility was managed and produced all requested paperwork. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Tiffany Lynch, House Manager, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.