Inspector’s narrative
What the inspector wrote
INVESTIGATION REVEALED THE FOLLOWING:
Allegation #1: Staff are not assisting resident with transportation.
The complaint alleges that the facility staff are not assisting Resident #1 (R1) with transportation. (R1) is not receiving adequate transportation support for medical appointments, requiring (R1) to find alternative transportation independently.
On September 28, 2023, between 10:10 AM and 1:15 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Four (4) out of the five (5) staff members reported that transportation for residents had been unavailable for approximately four months due to mechanical issues or a lack of proper documentation for the facility’s Mercedes-Benz Sprinter van.
On September 28, 2023, between 10:10 AM and 01:15 PM, the Department interviewed resident members identified as Resident #1 through Resident #3 (R1-R3). Three (3) out of the (3) resident members reported that staff informed them the facility van was out of commission for repairs and didn't have a current vehicle registration card. The resident must arrange alternative transportation using taxis or Uber rides, which are out-of-pocket costs for the resident and are non-reimbursable.
On March 29, 2025, between 09:25 AM and 11:45 AM, the Department interviewed resident members identified as Resident #4 through Resident #9 (R1-R9). Five (5) out of the six (6) resident members confirmed that the facility van was out of commission for several months in 2023 and had arrangements with family members to provide transportation services.
On March 29, 2025, between 11:50 AM and 12:30 PM, the Department interviewed staff members identified as Staff #6 and Staff #7. One (1) of the two (2) staff members recounted an incident from 2023 when the transportation van was rendered out of commission, impacting the daily routines and facilities operations. This unexpected breakdown had implications that extended inconvenience, affecting the staff's ability to transport individuals as needed efficiently.
The Department reviewed Resident #1 (R1)’s Residence and Care Agreement California (dated June 06, 2022). It outlined on page 9 subsection (G), title “Transportation,” indicated in part, "We will make available to residents, or otherwise assure the provision of, scheduled transportation to the nearest appropriate health facilities for medical and dental appointments, social services agencies, shopping, and recreational facilities within a 12-mile radius. (Evaluation Report continues LIC 9099-C)
This report serves as an amendment to clarify the finding. It does not supersede the complaint investigation findings reflected in the report created 03/29/25.
As a result, residents are entitled to scheduled transportation to medical and dental appointments within a 12-mile radius of the facility. Further review of the facility’s van temporary California Registration Care (dated September 12, 2023) and invoice for wheelchair lift replacement (dated September 11, 2023) validated the information provided by staff and resident statements.
The Department reviewed the facility’s transportation request forms from April 2023 to September 2023. It found that transportation for medical and dental appointments was not provided between May 12, 2023, through September 19, 2023. According to the facility's transportation log, transportation for Resident #2's medical appointment scheduled for May 16, 2023, was canceled. Additionally, the concierge was instructed not to make any transportation reservations until further notice.
On March 29, 2025, between 12:37 PM and 1:26 PM, the Department inspected the facility's Mercedes-Benz Sprinter van and confirmed that the van and the wheelchair lift were fully operational. However, the vehicle's registration tags from the Department of Motor Vehicles had expired in September 2024, demonstrating that the van is currently being operated with outdated registration.
Based on the gathered information, sufficient evidence is demonstrated to substantiate the validity of this allegation.
Allegation #2: Staff are not adhering to the admission agreement.
The complaint details alleged that the staff does not adhere to the admission agreement. It is reported that staff do not follow the admission agreement guidelines when regarding transportation services. Staff are not consistently adhering to the admission agreement guidelines for transportation services, which is a concern. This oversight compromises their commitment to providing reliable and practical support for the residents in care.
On September 28, 2023, between 10:10 AM and 1:15 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Three (3) out of the five (5) staff members confirmed that the facility has an enforced 10-mile radius policy for transportation services. This policy effectively regulates the transport of residents to their medical and dental appointments and social activities, ensuring that all travel remains within the specified boundary. This approach provided consistent support for residents' transportation needs. (Evaluation Report continues LIC 9099-C)
This report serves as an amendment to clarify the finding. It does not supersede the complaint investigation findings reflected in the report created 03/29/25.
On September 28, 2023, between 10:10 AM and 01:15 PM, the Department interviewed resident members identified as Resident #1 through Resident #3 (R1-R3). Three (3) out of the three (3) resident members stated that the facility is directing residents toward alternative transportation methods. This includes advising residents to secure taxi or Uber rides, or to arrange medical or dental transportation services through family members. Furthermore, all resident members, along with one staff member, confirmed that residents have been explicitly informed that they will not receive reimbursement for transportation expenses incurred for services within 10 miles of the facility.
On March 29, 2025, between 09:25 AM and 11:45 AM, the Department interviewed resident members identified as Resident #4 through Resident #9 (R1-R9). Five (5) out of the six (6) residents replied that the transportation van was out of service during 2023; they had to arrange alternative transportation for social, medical, and dental activities.
They were unsure about the transportation limited mileage policy and whether residents had to cover transportation expenses out of pocket.
On March 29, 2025, between 11:50 AM and 12:30 PM, the Department interviewed staff members identified as Staff #6 and Staff #7.
One (1) of the two (2) staff members confirmed that the facility could not provide transportation services with the non-operating van. Residents had to make their transportation arrangements along with an enforced 10-mile radius policy.
The Department reviewed Resident #1’s Residence and Care Agreement in California, dated June 6, 2022. This review revealed that the facility's “10-mile radius policy” is inconsistent with the terms outlined in the residential agreement, which outlines a "12-mile radius policy". Additionally, an entry in the facility’s Transportation Log from September 26, 2023, noted an appointment scheduled at 1:30 PM, which exceeded the specified 10-mile limit, further demonstrating the facility's implementation of this policy.
Based on the gathered information, sufficient evidence is demonstrated to substantiate the validity of this allegation
Based on observations, interviews, record reviews, and analysis, the preponderance of evidence standard has been met; therefore, the allegations that "Staff are not assisting resident with transportation" and "Staff are not adhering to the admission agreement" are determined
Substantiated
. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D.
An exit interview was conducted, and Activities Director Adriana Marquez was provided with a copy of this report and appeals rights.
This report serves as an amendment to clarify the finding. It does not supersede the complaint investigation findings reflected in the report created 03/29/25.
