Complaint·April 21, 2022

Regarding to allegation of facility has insufficient staffing to meet residents' needs- during the initial 10-day complaint inspection on 2/28/22 at 11:15am, LPA and the assistant administrator entered the TV / Dinning room in Memory Care Unit 3B, LPA observed resident #2 (R2) and resident #3 (R3) were watching TV by themselves. Then, LPA observed a staff was going in and out of the kitchen that is located in the dinning room and the dinning is in the same room as the TV room but separated by a wall. LPA observed the staff who was going in and out of the kitchen did not have visual supervision of both residents as the wall was in between the 2 rooms. A few minutes later the same staff completed his/her tasks in the kitchen and left the dinning/ TV room while both residents continued to watch TV in the TV room. Based on observation and interview during the course of the investigation, this allegation is substantiated. Based on observation and interview 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, and Appeal Rights provided. A copy of this report is provided. During the initial 10-day complaint inspection on 2/28/2022, LPA observed R1 was in the Terrace room passively participating in an activity in the presence of an activity staff, R1's private caregiver and a few other residents. LPA interviewed the facility directors who denied this allegation. LPA interviewed 4 facitliy staff who provided care to R1 and they reported that R1 was not left unattended, R1 did not fall and sustained injuries. LPA observed the LIC624- Incident Reports from Jan 2022 and there was not reporting of R1 falling. Concerning facility administered a flu shot to R1 without R1's responsible party's written consent. The administrator acknowledged the flu shot was given without a consent. Therefore, this deficiency will be cited on a LIC809. Base 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 allegation is UNSUBSTANTIATED. Exit interview conducted with the facility administrator. A copy is provided. LPA interviewed the facility director who denied the allegation. Based on interviews and observation during the course of the investigation, this allegation was deemed to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This report is discussed and reviewed with the administrator and the assistant administrator. A copy is provided.