Complaint·September 24, 2024

It was noted during interviews that R1’s one-on-one caregiver did not speak English and could not effectively communicate with the resident. Although the facility had implemented one-on-one supervision for R1 due to their known aggressive behaviors, the one-on-one staff was unable to prevent R1 from abusing another resident and could not redirect R1 to release R2’s hair. Interviews with Staff 1 (S1) revealed R1 had a strong grip on R2 leading R2 to an area adjacent from the area approximately 64 feet from where the incident first occurred. Staff stated this likely hurt R2 although Staff stated that after the incident R2 had a look on their face as though that they were in “shock” and R2 was holding the back of their head indicating they were in pain.” Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Illegal eviction. The SOC341 for the 8/29/2024 incident states R1 was picked up by their POA on 8/29/2024 at approximately 6:00 pm and R1 was discharged from the facility on 8/30/2024 due to the community being unable to meet R1’s needs. It was clarified through interview that after the incident on 8/29/2024, Executive Director Tyler Barnes through the Interim LVN Nurse Consultant directed LVN Consultant to contact facility staff to let R1’s responsible party know that R1 needed to be picked up within the next few hours or 9-1-1 would be called and R1 would be transported to the hospital and evaluated for “altered state of mind and return to baseline due to aggression and refusing medications". On 8/30/2024, Executive Director stated POA was notified via telephone that due to multiple aggressions and multiple medication refusals, that R1 is not appropriate to the community, poses risk to residents and staff because R1 is refusing the medications, and the respite is ended as 8/30/2024. Executive Director stated R1’s responsible party was not provided a written notice and provided additional resources available during the phone call. CCL received no written notice of eviction for R1 and it was confirmed R1’s POA did not receive any written notice of the eviction. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Facility staff did not properly report abuse. The facility submitted a self-reported incident report for R1 and R2 for an incident that occurred on 8/28/2024 at approximately 4:45 pm. The SOC341 abuse reporting form states it was sent to the local Ombudsman office and CCL on 9/5/2024. Further investigation revealed it was not faxed to the local Ombudsman office until 9/7/2024 at 10:40 am, and CCL has no record of receiving this SOC341. Please continue to 809-C, Pg 3. The facility could not provide proof that the SOC341 was submitted to CCL. This did not meet the 24-hour reporting timeframe requirement per AB 1417 and CCR 87211(c), and which are also listed in the instructions of the SOC341 form. Additionally, another SOC341 for an incident occurring on 8/31/2024 also was not sent to the Ombudsman office until 9/7/2024. CCL received the incident report for this incident via email at 9/7/2024 at 6:00 pm but no SOC341 was received by CCL. Based on the information obtained, the allegation is deemed Substantiated at this time. The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. Copy of report and appeal rights issued at the time of the visit.