complaint·August 2, 2024

It was alleged that staff (S3) left a resident (R3) soiled for an extended period of time. On 07/10/2024, 7 residents, 6 staff members, and 1 witness were interviewed. Based on staff interview, after a shift change staff (S4) observed R3 was left in double diapers with both diapers filled with R3’s stool. It was stated that the AM shift caregiver left R3 in soiled double diapers since the morning. The review of records show that on 05/28/2024 care staff documented their observation of R3 being left in dirty double diapers with stool from the AM shift. The Department has investigated the above allegation and the preponderance of evidence standard has been met, therefore, the above allegation is SUBSTANTIATED. A deficiency was cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with Executive Director, Alex Baisu and a copy of the report and appeal rights were provided. PAGE 2 OF 2. Staff handles residents in a rough manner It was alleged that staff (S1) handled resident (R1) in a rough manner by squeezing R1’s arm when transferring. It was alleged that R1 stated they were hurting and S1 would yell stating he/she is not doing anything. On 07/10/2024, 7 residents, 6 staff members, and 1 witness were interviewed. Based on staff interviews, a staff (S2) witnessed S1 squeeze R1’s arm during a transfer. S2 states that he/she did not believe S1’s intention was to hurt R1. S2 states R1 was not hurt and did not observe any bruises on R1 after the incident. 4 out of 6 staff denied the observation of a staff squeezing R1’s arm. 1 out of 6 staff states to have heard of this incident occurred from another staff member. Based on resident interview, R1 did not think S1 squeezed his/her arm when assisting him/her during a transfer. It was stated that staff treats R1 nicely and none of the staff has hurt him/her. 6 out of 7 residents denied staff handling them in a rough manger. 6 out of 7 residents denied the observation of staff handling other residents in a rough manner. 1 out of 7 residents stated that sometimes the new staff are a little rough when handling R2’s care needs. R2 was unable to provide names of the staff and dates of when these incidents occurred. Based on witness interview, W1 denied observing staff handle residents in a rough manner. Staff yells at residents in care It was alleged that staff (S1) yells at resident (R1). It was also alleged that staff (S3) yells at the residents. On 07/10/2024, 7 residents, 6 staff members, and 1 witness were interviewed. PAGE 2 OF 3. Based on resident interviews, R1 denied staff yelling at him/her. It was stated that staff treats R1 nicely and none of the staff has hurt him/her. 7 out of 7 residents denied staff yelling at the residents. 7 out of 7 residents denied the observation of staff yelling at other residents. Based on staff interviews, 6 out of 6 staff members denied the observation of staff yelling at the residents. Staff does not ensure resident’s medications are administered It was alleged that staff (S3) does not ensure R3’s medications are administered and it was alleged that the resident’s medication was found on the resident’s floor. On 07/10/2024, 7 residents, 6 staff members, and 1 witness were interviewed. Based on resident interview, 4 out of 7 residents does not have medication management. 3 out of 7 residents interviewed has medication management. 3 out of 3 residents state the staff administers their medications daily. 3 out of 3 residents denied issues or concerns regarding their medication administration. Based on staff interview, 6 out of 6 staff state the residents are being administered their medications. 6 out of 6 staff denied the observation of seeing loose medication on the floor. On 07/10/2024, LPA Dolores audited R3’s medication with staff. Based on observation, R3’s medications are being administered per doctor’s orders. The Department has investigated the above allegations. Based on interview, record review, and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Alex Baisu and Valentine Mathangani, Health & Wellness Director III a copy of the report was provided. PAGE 3 OF 3.