Complaint·May 4, 2021

Regarding to facility does not have scheduled activities, LPA Han reviewed the weekly Activity Calendar, interviewed the Director of Activity, the residents and the Responsible Parties. The Director of Activity explained that the Activity calendar is being created on a weekly basis and it is being delivered to the residents, emailed to the family members and posted by the Temple which is the main Activity room. The residents concurred that they receive the weekly Activity calendar as well as the Responsible Parties and they are aware when the Activities take place. The Director of Activity reported that they have not received any concerns regarding the Activity program recently but during the beginning of the Pandemic, one resident expressed unsatisfactory of cancelling all the group activities. Base on record review and interviews during the course of investigation, this allegation is unsubstantiated. Regarding to staff are not reporting incidents, LPA Han reviewed the Incident Reports that were submitted by the facility to the Licensing Office and validated it that those reports were faxed on time. In addition, LPA Han interviewed the Director of Resident Care regarding to the facility's incident reporting protocols and she stated that the staff member who discovered the incident completes the Internal Incident Report and then the staff members would proceed with other protocols including notifying the Responsible Parties. LPA Han interviewed Medication Manger who stated that when there is an incident, they complete a list of protocols including but not limiting to notifying the Responsible Party. LPA Han interviewed Medication Technician who stated that when there is an incident, they make sure the resident is safe and proceed with other actions such as reporting it to the respective Responsible Party. LPA Han spoke to the Responsible Parties and they confirmed that they were notified in a timely manner for incidents including but not limiting to falls. Base on record review and interviews during the course of investigation, this allegation is unsubstantiated. ** Report Continued on next page** Regarding to facility Administrator did not complete the required 80 hour RCFE Certification Class, the 80 hour training record was not received, however, in order for the Administrator to apply for the Initial Administrator Certification, one of the requirement was to submit the training records. LPA Han reviewed the Administrator Certifications since 2012 and validated that the Administrator obtained the Administrator Certification in 2012 and it is current. Base on record review and interviews during the course of investigation, this allegation is unsubstantiated. Regarding to the facility staff have not received required training, LPA Han reviewed in-service records, interviewed the Administrator, the staff members, the Responsible Parties and the residents. The Administrator explained that due to the Pandemic, most of the staff training classes were done on-line but some were still completed in person. The staff members concurred that they were trained but mostly on-line. The residents expressed that the staff members are trained to care for them and the Responsible Parties witnessed that staff members were knowledgeable of their job duties and they were aware of the resident's daily routines. Based on record review and interviews during the course of investigation, this allegation is unsubstantiated. Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted with the facility's Administrator over the phone. The facility Administrator will receive this LIC9099 report through email to sign and email it back to LPA Han.