Complaint·November 2, 2022

Based on the memory care staff assignment sheet, there are 5 slots for 5 facility staff on am and pm shifts and 4 slots for 4 facility staff on the night shift. LPA reviewed the assignments from 8/3/2022 - 8/14/2022 and observed multiple open shifts, multiple staff names were crossed out due to no shows, and staff working double shifts to cover for open shifts. After the investigation, this allegation is substantiated. Regarding to the allegations of facility is unkempt, according to the reporting party, during their visits of resident #1 (R1) who resided in the memory care unit, they witnessed R1's room was dirty, feces around the toilet seat, dirty adult brief on the bedside table, and dirty clothes on the floor that should have been brought to the laundry by staff. As part of the investigation, on 9/7/2022, LPA toured the memory care unit with the facility director and made the following observations: At 11:10am, LPA and the director went into room 110, and observed resident in bed, there was as a dried brown stain on the coach, there were white particles on the floor by the head of the bed, there was dirty clothes on the floor by the kitchen. According to the staff #2 (S2), the room has not been cleaned by the housekeeper. At 11:23 am, LPA and the director went into room 118 and observed resident in bed, a pair of shoes and 2 pairs of wheelchair footrests placed on top of 2 chairs. According to staff #3(S3), the room has not been cleaned by the housekeeper. At 11:40 am, LPA and the director went into room 120 and met with resident #2( R2) who stated that the room has not been cleaned and it has not been cleaned as often as it should be. LPA and the director observed dried brown/black spots inside the toilet bowl, dry crumbs on the floor and rusty/dusty fan. According to the director, this room should have been cleaned already but he/she was not sure if it was actually cleaned as the assigned housekeeper called in sick and the director did not know which staff was replacing the sick call. LPA interviewed 5 housekeeping and maintenance staff who were on duty on 9/7/2022 and all of them reported that they did not clean the memory care unit on that day as they were not assigned to it. After the investigation, this allegation is substantiated. Regarding to the allegation of facility staff failed to provide a safe and comfortable environment for resident, due to the above findings, this allegation is substantiated as the facility was found to be unkempt, uncleaned, unsanitized, and uncomfortable for residents. After the investigation, this allegation is substantiated. Based on interviews, observations and record review during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator, a copy is provided and Appeal Rights provided.