complaint·April 23, 2025

Continued from LIC9099 “Staff do not respect residents privacy by posting pictures online without consent” – Complainant alleged that Staff Member 1 (S1) violated residents’ privacy by posting pictures of residents on their personal social media account. LPAs were provided with photos, a video, and resident names. Review of S1’s file showed that they received a write up for posting activity events with residents on their personal social media account. Interview with prior Executive Director stated that S1 was given verbal permission to post events by a different Director since they did not have access to the business account. LPAs reviewed a sample size of 6 resident agreements. 5 of 6 files did not have signed social media consent forms or “model release agreements.” Per interview with Community Relations Director, all agreements were signed electronically and the consent forms could have missed during signing. LPAs identified that the residents provided in the photos did not have signed social media consent forms. Based on interviews conducted, document review, and observations made, this allegation is Substantiated . “Facility has insufficient staffing to meet the needs of residents in care” – Complainant alleged that facility management is allowing one care staff member in each house and refuses to help when they are short-staffed. LPAs conducted interviews. Per interview with prior Executive Director, facility has not had adequate staffing to meet resident care needs. Interview with current Executive Director stated that 4 of the 5 facility houses require at least 2 staff members based on resident care needs such as transferring or bathing. Review of facility documents indicated that at least 6 residents in the community require 2-person assistance with care. Based on interviews conducted and document review, this allegation is Substantiated . “Facility is obstructing facility exit” – Complainant alleged that facility management is instructing staff members to block the exit door to prevent residents from escaping. LPAs were provided with a photo during the investigation. Photo provided showed that a facility exit door was obstructed by a gray couch. Based on observations made, this allegation is Substantiated . A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents. Continued from LIC9099 LPAs were provided with a photo which showed S1 standing next to a male resident wearing gloves. The male resident is sitting down at a table. From the photo provided, it is unclear what S1 is doing in the photo as their hands are obstructed by items on the table. Review of facility’s Clinical Policy and Procedure Manual for Podiatry and Nail Care states the following: “Policy: The Community will arrange or make available to residents foot and nail care. Procedure: Personal Care Assistants will not trim toenails, smooth corns, calluses, etc. The Resident Care Director will schedule podiatry appointments for all foot and/or nail care other than cleaning and moisturizing…” Review of S1’s file showed that they did not have training to provide nail care. Interview conducted with S1 stated that they provided an activity called “Nail Spa” which included placing warm towels over resident nails, filing and painting them. S1 denied cutting or trimming resident nails. Interviews conducted with other facility staff provided conflicting information. 4 of 8 interviews stated that S1 has not been seen cutting or trimming resident nails, while 4 of 8 interviews stated that S1 has been seen cutting or trimming nails. Based on interviews conducted, document review, and observations made, this allegation is Unsubstantiated . A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.