Complaint·January 19, 2025

Allegation: Staff sleeping in resident’s room during a shift. The investigation into the allegation of staff sleeping in a resident's room during a shift consisted of interviews and observations. Interviews with the facility administrator and staff members indicated that staff members are attentive and present during their shifts, with no evidence of staff sleeping in resident rooms. Administrator Jennifer Flores confirmed that there is no live-in staff at the facility, and the staff schedule shows that there are two staff members on duty during the day and evening shifts, with one staff member on the night shift. Staff members that were interviewed reported that they remain attentive to residents' needs throughout their shifts, ensuring residents receive the necessary care and attention. During the site visit on 11/23/24, LPA observed two staff members on duty, and there was no indication of staff being inattentive or sleeping in any resident room. Additionally, a review of past inspection reports made from the Department, dated 11/23/24, 9/12/24, 11/19/22, 8/3/22, 3/9/22, and 9/17/21, did not reveal any evidence of staff sleeping in resident rooms. Based on the information gathered during this investigation, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation: Inadequate staffing to meet the needs of the residents in care. The investigation into the allegation of inadequate staffing to meet the needs of the residents in care consisted of interviews, record reviews and observations. Interviews with the facility administrator and staff members indicated that, despite occasional challenges related to staffing shortages, the facility generally maintains an adequate number of staff to meet the needs of its residents. The administrator, Jennifer Flores, acknowledged that there are times when staffing is reduced, particularly in the night shift, where only one staff member is on duty. However, staff on the day shift reported that they are able to meet the residents' needs effectively, even with minimal staffing at times. Furthermore, interviews with staff confirmed that there are typically two staff members on shift, and they manage to attend to the needs of the residents, who generally do not have very high care needs. Additionally, staff stated that while there was a temporary staff shortage due to resignations, they are still able to attend to residents and manage their care, including addressing toileting needs. Furthermore, during the site visit, LPA observed two staff members on duty, residents engaging with staff in the living room, and no indication of staff being overwhelmed by residents’ needs. Despite having short staffing issues in the past, it is unclear that the facility was inadequate to meet residents’ needs. Based on the information gathered during this investigation, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. {2 of 3} Allegation: Facility not providing activities to residents. The investigation into the allegation that the facility is not providing activities to residents consisted of interviews, record reviews and observation. Interview with the facility administrator, Jennifer Flores, confirmed that the facility has an activity schedule in place, with daily activities planned from Monday to Friday. The weekends are left open, as this is when families typically visit and take residents out. The facility also has activity supplies available, which were observed during the site visit on 11/23/24. Additionally, staff members indicated that they attend to residents' needs, including those who participate in activities. While the administrator acknowledged that staffing shortages sometimes impact the consistency of activities, the facility does make an effort to follow its activity schedule. On the day of the visit on 11/23/24, residents were observed engaging with staff in the living room, watching TV, and conversing. Based on the information gathered during this investigation, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Based on today's visit, no deficiencies are being cited. Exit interview was conducted with Jennifer Flores, Administrator, via phone. S2 signed this report. A copy of this report and appeal rights were provided. {3 of 3}