complaint·February 13, 2023

Complaint alleges that Staff do not respond to resident's call for assistance in a timely manner. Based on interviews that were conducted with staff, LPA learned that Resident #1 does wear a Call Pendant. During the opening of the complaint on January 31, 2023, the previous Administrator denied that Memory Care residents wear a call pendent. However, LPA observed Resident #1 wearing a Call Pendant. (See LIC 812, interview dated for January 31, 2023, titled: Interview-Administrator) Furthermore, LPA reviewed resident records which included the Call Pendant log for Resident #1 from January 20, 2023 through January 23, 2023 and learned that Resident #1 had eight instances of response times lasting more than 20 minutes and an average response time of 2 hours and 27 minutes with some instances lasting hours (See LIC 9099D) . Previous Administrator disclosed to the LPA that there was no history of Call Pendant Logs for December 2022 for Resident #1. Complaint alleges that Staff are not adequately trained to meet the needs of residents in care. LPA reviewed facility records which included the staff training records, interviewed staff and residents in care. In addition, on February 6, 2023 during a subsequent complaint investigation inspection, LPA reviewed staff training records with the Regional Vice President and Assistant Executive Director and learned that 10 staff members including the former Administrator did not have the proper training hours necessary (See LIC 9099D). Complaint alleges that Staff do not answer the facility after hours phone line. During the opening complaint on January 31, 2023, LPA requested the after hours call history for the phone that is designated as the after-hours phone line. LPA reviewed those records at the facility and learned that on January 20, 2023 and January 24, 2023 phone calls were missed and not returned back in a timely fashion. In addition, on February 06, 2023, during a subsequent complaint investigation inspection, LPA and Regional Vice President reviewed the call history log for the after-hours phone together, LPA showed the said dates (January 20, 2023 and January 24, 2023) to the Regional Vice President and the missed calls associated to those dates (See LIC 9099D). Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeated deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Administrator and appeal rights were given along with this report. A finding that the complaint allegation of Staff do not ensure residents hygiene needs are met is unsubstantiated meaning 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. Exit interview was conducted and a copy of this was report was signed and given to the Assistant Administrator.