complaint·May 19, 2025

During LPA Dolores’ visit, 4 staff were observed to be working. During LPA Donato’s visit there were about 5 staff working, some are with residents in the dining area, some were at the living room watching tv with the residents. LPA also observed that when a resident called for help, a staff was there to attend to the resident. For the allegation of facility not following their infection control policy, RP stated that COVID protocol/infection control not properly implemented when there is an outbreak. LPA interviewed staff members. S1 stated that they do have isolation rooms in case there is an outbreak. It's located in between the office and main rooms.There's a separate entrance with ramp. LPA documented the area through photos. Food is left to the staff room in between the isolation room and hallway and is taken by a staff assigned to serve it to residents. Incident reports are also submitted to licensing. Regarding the allegation of Licensee/ADM is not carrying out his/her responsibilities and authority to carry out the policies of the facility, RP stated that owners of the facility area always out of the country and doesn’t care what’s going on in the facility. During the interviews, S1 and S2 stated that Administrators Judith and James Morales is here basically every day when they are here in the area. Based on records review, there are other staff who are qualified administrators also and are there when Licensees are not around. Although the allegations may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are deemed UNSUBSTANTIATED. Report is reviewed and copy is provided. Regarding the allegations of Residents medications are not being administered per physician’s order and residents’ medications are accessible, Reporting Party (RP) stated that medications are not properly administered/caregivers are giving meds instead of the med-clerk/some residents are hiding medication in their room without proper documentation. Based on records review, 5 out of 5 resident’s medication administration records (MAR) have accurate logs of when medications are given to residents. It is also noted in the MAR if medications are discontinued. Facility also has an updated Centrally Store Medication & Destruction Records (CSMDR) for the 5 residents. During the visit of LPA Dolores, it was observed that a medication cart in the dining room which was observed locked. LPA Donato, on the subsequent visit, also observed this medication cart and PRN medications were locked inside a room in one of the offices. LPA Donato also toured random rooms. LPA checked all the closets and cabinets and only saw body lotions and wipes for the residents. There were no medications found in the rooms. Regarding the allegation that the facility does not have sufficient lights to ensure the comfort and safety of residents and facility is unsanitary, reporting party (RP) stated that The facility is dark not too filthy but there is an unexplainable smell when we toured. During the initial visit, LPA Dolores toured the facility and observed that the smell of the facility to smell like multiple perfumes and air fresheners. The facility was clean and sanitary with clean floors and surfaces. Resident bedrooms well kept. The beds were made, no random items and objects laying around the floor. The floors observed with no obvious dirt marking and sticky surfaces. Fire exits were free and clear of obstruction. LPA observed the hallways were dim when the lights are off. Hallways and dim spaces contain light switches. LPA observes the areas were well lit once lights were turned on. LPA Donato also visited and observed that the facility is clean and well maintained, there were night lights in the facility hallways. The residents’ rooms are well kept. page 2 of 3 For the allegation of facility has a staff member who is not fingerprinted, RP stated that Facility is harboring undocumented employee mostly working at night. LPA Dolores checked on the staff that works and lives in the facility. All three staff members who resides on the 2nd floor of the facility are all fingerprinted and associated in the facility. The facility has apartments at the back. LPA Donato crosschecked the people living there during the time of complaint and everyone is associated with the facility and fingerprint cleared, one being a non-client adult resident due to the person just residing in the apartments and not working as staff. For the allegation of Facility has a kitchen in the second floor, which is a fire hazard RP stated that Staff rooms upstairs is filthy and has a kitchen that is dangerous to fire. LPA Dolores toured the 2nd floor and it was observed that it contained a kitchen. The kitchen did not have a stove. LPA observed a vintage oven connected to the wall. S1 states the oven is not working. S1 opened the oven and LPA observed the oven was filled with storage containers. The kitchen area had 2 refrigerators, a microwave, dining table, and rice cooker. LPA observed a fire extinguisher sitting on the kitchen table. Based on observations & records review the department has determined that that these allegations are false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. Report is reviewed and copy is provided. page 3 of 3