Complaint·March 28, 2022

Regarding the allegation that the facility administrator does not spend sufficient amount of time at the facility, according to the complainant, facility administrator comes to the facility sporadically and mainly to deliver groceries, and she divides her time between two facilities; therefore, she is not present at the facility sufficient amount of time required to ensure that the facility operates accordingly. During the investigation, LPA interviewed staff and it was indicated that the administrator is in the facility 2-3x a week or once every two weeks to deliver groceries. Nevertheless, LPA Charitra interviewed the administrator and it was acknowledged that he/she comes to the facility 3x a week for 2-4 hours. Based on LPAs observations and interviews which were conducted, it was determined that the administrator does not spend a sufficient amount of time at the facility to meet the administrator qualifications and duties. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Regarding the allegation that the facility is not following program design, according to the complainant, the facility program design requires a 1:1 care between caregivers and residents; however, there are only two staff members providing care and supervision to 3 residents. LPA Charitra reviewed the plan of operations and verified that the facility submitted and got approved a program design requiring 1:1 staffing provided during most waking hours and two staff providing awake supervision and care during sleeping hours. On January 21, 2022, when LPA Charitra conducted the 10-day complaint visit at the facility, LPA observed 3 residents and 2 staff members, one of which was shadowing that day. This indicates that the facility failed to follow the stated plan of operations. Interviewed staff indicated that since the facility went through a change of ownership, the facility has not been able to meet 1:1 care. According to the Administrator, the facility is trying to hire more staff and is trying to comply to the 1:1 program design but it’s been difficult due to staffing. Nevertheless, the licensee failed to follow the program design in order to meet the resident’s care and supervision. Based on the interviews and documentation, it was determined that the licensee failed to follow the program design and to ensure the proper care and supervision for the residents. Furthermore, the licensee failed to address the staffing concern and find alternative solutions to meet the program design. The preponderance of evidence standard has been met; therefore, this allegation is SUBSTANTIATED. Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with House Manager, Homer Bautista, and a copy is provided. Regarding the allegation that the facility administrator provided Licensing with false claims, regarding staffing and resident relocation; On January 12, 2022, LPA Jamie Vado spoke to Administrator regarding the COVID cases at the facility. According to the administrator, the facility at the time did not have any positive residents and there was a sufficient number of staffs to care for the residents. During the exchange, there was a question whether residents had been relocated to accommodate supervision. The Administrator first denied the relocation, and then reported that indeed there had been a relocation. However, during the investigation, staff interviewed, and information collected indicated that the facility has been short on staff but did not relocate the residents at any point. Therefore, based on the information collected, and interviews, the allegation that the facility administrator provided licensing with false claims regarding staffing and resident relocation is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Report is reviewed with House Manager, Homer Bautista, and a copy is provided