complaint·September 1, 2022

No training records were produced by the licensee until the date of 08/19/2022, over a year and three months past the initial request for records. In this submission of training records, the only record of medication training the Licensee submitted was for staff S4 who had: 1 hour of training in, Minimizing Medical Errors, dated 09/17/2021; 1 hour of training in, assisting with self-administration of medication: Guidelines, dated 01/01/2021; 1 hour of training in, Medication Documentation for California, dated 07/19/2022. All the training listed above was completed after the date of incident related to this complaint, subsequently there is no evidence that any staff was properly trained to administer medications during the time of the allegations to this complaint. Interviews of Staff 1 – 6 confirmed that all staff interviewed passed medication to residents in care and that is a normal practice of the facility. Based on interviews and documentation the allegation of, “Staff are not properly trained to give medication.” Is substantiated at this time. As to the allegation of, “Facility floor is in disrepair.” It was discovered though documentation, interviews, observations, and photographic evidence that the facility floor is in disrepair. It was observed by Licensing Program Analyst (LPA) Jeffries on 08/16/2022, on the first floor it was observed in the main living/dining/entrance area that several planks of laminate flooring are separating from each other and need repair or replacement. It was observed by LPA on 08/16/2022 that the first bedroom to the right on the first floor also had laminate plank flooring that were separating and in need of repair or placement. On 08/16/2022, LPA observed in the hallway of the first floor several areas where the planking is separated. On 08/16/2022, LPA observed on the second floor kitchen area next to the sink where an attempt to repair the loose laminate planking were screwed in by approximately six wood screws, however the planks were still separated and the floor in an area in front of the sink would fall 1”-3” inches when LPA walked over that area of the floor, approximately 40 square feet of flooring bowed 1”-3” in front of the upstairs sink. On 08/16/2022, LPA observed the floor in the upstairs living room towards the center of the living room would also bow 1”-3” up and down when LPA walked over the described area which is approximately 40 square feet. On 08/16/2022, LPA observed several door thresholds throughout the facility being in disrepair and creating a possible tripping hazard for residents in care. CONTINUED on LIC9099-C On 08/16/2022 LPA observed the door to room 3 on the second floor to be very difficult to open and shut due to miss alignment which may be related to the disrepair of the second story floor as there was no observational evidence of the hinges being bent, broken, or dislocated. All areas observed by LPA are supported with photographic evidence. It was also observed by LPA Chavez on 05/11/2021, that a “water puddle and leak of approximately six (6) inches in diameter in downstairs laundry room floor to the right of sink cabinet” as well as “floor is disrepair” in resident’s room, with provided photographic evidence provided. On 06/16/2021, LPA Chavez noted that she observed the same disrepair's, noted on LIC9099. On 08/16/2022, Licensee send by email to LPA a profit Loss summary indicating the cost of repairs and maintenance for the time period of January 2019 through June 2021. The only specific repairs noted each year on this summary were of the laundry machines. The other line items on the summary were building repairs, equipment repairs and building maintenance, however there are no specific repairs noted on this summary in those categories that indicated any floor repairs were made, which is all prior to the time frame of this complaint (April 2021 through July 2021). The only observational repairs made were the 6 wood screws noted by LPA on 08/16/2022. Interviews of Staff (S1-S5) provided no evidence that floor repairs were made to the facility. Due to observations, lack of documentation and interviews, the allegation of, “Facility floor is in disrepair.” Is substantiated at this time. Exit interview, citation issued, report signed, report and appeal rights emailed. As to the allegation of. “Facility has mold.” It was discovered through interviews and observations that the facility was free of mold. Interviews of Staff (S1-S5) did not reveal any credible recollection of mold being present at the facility during the time of April 2021 through July 2021 and during the Licensing Program Analyst (LPA) tour of the facility on 08/16/2022. Due to lack of evidence the allegation of, “Facility has mold.” Is unsubstantiated at this time. As to the allegation of, “Facility is no being cleaned properly.” On 08/16/2022 visit of LPA Jeffries, there were no visible indications that facility is not being cleaned properly and it could be concluded that the observations on 06/16/2021 pertaining to facility cleanliness could be contributed to facility daily operations and the time of visit. It was discovered through interviews that all employees have secondary duties dedicated to keeping the facility clean and sanitary. Interviews of Staff 1-5 indicated that the staff do have cleaning duties as a secondary job duty. Based on observations and interviews there is not enough evidence to support the allegation of, “Facility is not being cleaned properly.” and is unsubstantiated at this time. Exit interview, report signed, and report emailed.