complaint·July 10, 2025

Continued from LIC9099... Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. Exit interview conducted with Administrator, whose signature on form confirms receipt. Continued from LIC9099A... LPAs did not find any other incident reports of elopements, Health and Wellness Director (HWD) informed there has only been the one in 2025 that fits the parameters of this situation of a resident leaving the facility and staff not visually seeing them. Administrator informed and training records obtain corroborate from 3/4/25 to 4/15/25 facility began 2X per week (sometimes more) preventative elopement training drills totaling 17 for this time frame. Complainant also alleges “the facility is dangerously understaffed”. Interview with Administrator and records reviewed revealed for April 2025 facility is fully staffed with 3 LVN’s, approximately 20 Med Techs (AL: 3 on AM, 3 on PM, & 2 on NOC) MC 1st floor (1 AM, 1PM, & 1 NOC) MC 2nd floor (different MT’s ,1AM, 1PM, & 1 NOC) 70 Caregivers-AL (AM-7, PM-7, NOC-4) MC 1st floor(AM-4, PM-4, NOC-2) MC 2nd floor(AM-4, PM-4, NOC-3). Resident assistant level for April 2025 -2 person assists - 7 in MC (split in the 2 units) & 10 in AL (also split between 3 levels), 50 (1) person assist & 94 no assist. Based on information provided, alarms were turned off, and not necessarily due to lack of staffing. There was no information obtained that supported a violation had occurred. Therefore, the allegation Staff does not provide adequate supervision resulting in residents wandering away from the facility is Unsubstantiated. Staff are not properly trained to meet residents' care needs – Complainant alleges unlicensed staff are routinely instructed by management to insert urinary catheters and perform catheter. LPA attempted contact with complainant 3 times but was unable to get response for follow up questions. Interview with HWD revealed there are 6 residents receiving catheter care and Home Health staff does all of the care regarding this. Administrator indicated Facility protocols indicate catheters are allowed and the care partner can ONLY empty the catheter and HWD will arrange with third party (HH, hospice or MD office) to change the catheter and if the catheter is pulled staff are to send them out to hospital to get it reinserted, unless the third party made arrangement to come right away to reinsert at the community. The staff need to be trained how to empty the catheter and what to look for reporting. Each resident with catheter must have individualized in-service and care planned according. Supplies for any catheter needs, are NOT paid by the community. There was no information obtained that supported a violation had occurred. Therefore, the allegation Staff are not properly trained to meet residents’ care needs is Unsubstantiated. Continued LIC9099C... Continued from LIC9099C... Staff does not ensure facility is free of bed bugs- Complainant alleges when resident (R3) was admitted to facility they had a bedbug infestation that was withheld from staff. Documents reviewed reveal R3 care notes from move in to 4/14/25 do not indicate any Bedbugs, Medical/mediation assessment of 4/10/2025 also does not indicate Bedbugs, and R3’s initial assessment of 4/11/25 indicates Resident’s skin is clear and intact & resident utilizes base services laundry, one load of linen & one load of clothing. 4/15/2025 Interview with Administrator indicated they do not have any bedbugs in the facility that they are aware of. 5/29/25 interview with staff HWD also indicated to the best of their knowledge there is no bedbugs in the facility, “We would definitely be getting calls from residents and observing bites and rashes of unknown origin”., therefore the allegation Staff does not ensure facility is free of bed bugs is UNSUBSTANTIATED. Staff do not follow proper infectious disease protocols - Complainant alleges several residents tested positive for MRSA, yet there was no PPE provided outside their rooms. Interview with Administrator in April 2025 revealed there are no contagious diseases currently. Facility had one AL resident (R1) on precaution that came back from the Hospital approximately 2 weeks ago with it but is no longer a concern. This was only contact precautions and R1 was here only 1 day before returning to the hospital. Full isolation containers were outside of room with (gloves/gowns/goggles). Interview with HWD corroborates Administrator indicating R1 was detected with MRSA in urine and went out to hospital next day. Facility implemented containers of PPE outside of this room. Based on information provided there was only 1 resident with contact precautions of MRSA and PPE was implemented outside of their room, although they were only in the facility 1 day prior to being sent out. There was no information obtained that supported a violation occurred. Therefore, the allegation Staff do not follow proper infectious disease protocols is UNSUBSTANTIATED. A finding that the complaint allegations are unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED . No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt. Continued from LIC9099A... Therefore, the allegation Staff are not properly assessing residents prior to admissions is Unfounded. This agency has investigated the above allegation alleging Staff are not properly assessing residents prior to admissions. We have found that the complaint allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.