complaint·August 28, 2023

Continue from LIC 9099) It was specifically alleged that on January 25, 2022, R1 was observed ungroomed with dirty hair and dirty clothes at the day program. According to outside sources, this was not the first time R1 had been observed in similar conditions. However, details of any other incidents when this occurred were not provided during the investigation. A review of R1’s services care plan indicated that R1 was ambulatory and needed assistance with showers and incontinence care. A review of the facility’s resident’s shower schedule indicated that R1 received showers twice a week on Sundays and Wednesdays. However, interviews with staff indicated that R1’s shower schedule was not always consistent due to R1 refusing to take showers as scheduled. Staff would accommodate R1’s wishes by providing flexibility and offering showers the next day or the following day as necessary. Staff stated that they tried to at least provide showers once or twice a week as necessary to meet R1’s needs. Staff documented each time R1 refused showers and the next day’s shift staff would follow up with shower attempts. During a visit conducted on January 31, 2022, and again on August 28, 2023, R1 was observed to be clean, groomed, and wearing fresh clean clothing. In addition, R1’s room was observed to be clean and free from odors. Interviews with outside sources indicated no concerns with residents not being showered as scheduled to meet residents' needs. Based on observations, record reviews, and interviews with staff and outside sources there was insufficient evidence to support the allegation that staff did not meet R1’s hygiene needs. It was also alleged that staff did not meet R1’s incontinence care needs. It was specifically alleged that R1 would arrive at the day program without wearing adult briefs and as a result, R1 would wet their pants. During interviews, facility staff indicated they would always make sure R1 wore adult briefs before leaving the facility for the day program. However, staff stated that it was typical behavior for R1 to take off their adult briefs multiple times during the day. Staff indicated that R1 did not always wear adult briefs during the day because they could at times independently use the restroom without assistance. R1’s service plan included incontinence care mostly to meet R1's needs during the night. Staff conducted incontinence care every 2 hours at night or as needed to meet R1’s needs. However, during the day, staff encouraged independence and tried to accommodate R1’s needs by providing flexibility about not wearing adult briefs as much as possible. Instead, staff provided reminders and prompting for R1 to take bathroom breaks as needed to meet their needs. Interviews with outside sources consistently indicated that staff were meeting residents’ incontinence care needs through individual toileting plans. Based on observations and multiple interviews, there was insufficient evidence that staff were not meeting R1’s incontinence care needs. (continue at LIC9099C Continue from LIC9099C) 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 Calais Anguiano, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) was provided at the conclusion of the visit.