complaint·July 19, 2023

The photograph provided shows the facility’s fence is not in good repair. On 06/04/2020, the Administrator provided a follow-up photograph to the Department showing the fence repair. The Department has investigated the above allegation and the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. A deficiency was cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with the Administrator, Bhupinder Kaur and a copy of the report and appeal rights was provided. The following documents were obtained to include R1 – R8’s physician’s report, appraisal needs and services plan, functional capabilities assessment, facility resident roster from January 2020 – February 2020, personnel report from January 2020 – March 2020, plan of operation, and police report records. From 05/08/2020 – 06/11/2020, 3 out of 3 staff were interviewed. Based on interview, the facility has live-in staff on premises at-all-times and are not required to be awake throughout the night. Based on interview, the facility does not have door alarms installed but staff can hear when someone opens the door. Two Administrators stated the facility did not have a resident who fit the description provided by the reporting party. The review of records shows the facility’s dementia plan of operation stating night staff will be required if any resident with dementia is determined to require an awake night supervision. The review of additional records shows the police department responded to the facility on 2 occasions in March and May 2020. Both occasions were not regarding an alleged resident who left the facility around 4:00AM and who fit the description provided by the reporting party. The Department has investigated the above allegation. Based on interview, record review, and observation the department has found the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to show the alleged violations did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Bhupinder Kaur and a copy of the report was provided.