complaint·August 1, 2025

Continued from LIC9099... On 7/9/25, LPA conducted a 10-day visit to the facility, made observations, obtained pertinent records and conducted interviews with staff. During the visit, LPA requested S1 to demonstrate how do staff were trained to properly transfer a resident who needs two-person assistance. S1 reached out to another staff (S2) and told them in Spanish "ayudame con esta", which translates to "help me with this" not referring to resident's name. Once S2 came to the resident’s room, both caregivers initiated the transfer without communicating their intentions to the resident. Upon LPA’s inquiry about both staff not communicating with R2 their intention of transferring R2 from their wheelchair to their bed, their response was that R2 was non-verbal, but they stated that R2 could hear us perfectly. However, they never communicate with R2. Based on staff training records for both caregivers it indicates that staff have received personal rights training, including the dignity of residents and personal care with residents’ transfers within the last year. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Another allegation of facility staff did not follow physician care orders. The Reporting party stated that on 6/27/25, R1 was observed to be transferred using one-person assist by staff (S1), S1 lifted R1 by their upper extremity, which R1 has repeatedly identified as a source of pain. Despite doctor’s order to use a gait belt, S1 continue to use extremity during transfers, these instructions do not appear to have been followed. On 7/9/25, During the visit, LPA requested S1 to demonstrate how do staff were trained to properly transfer a resident who needs two-person assistance. S1 selected resident (R2) who was in the common area in their wheelchair with other residents watching tv. S1 initiated pushing R2's wheelchair towards their bedroom without notifying R2 of the reasons why they were been transferred to their room, then S1 reached out to another staff (S2) to help with transfer. Once S2 came to R2’s room, both caregivers initiated the transfer without communicating their intentions to the resident, wheelchair was not positioned near nor parallel to the bed, both lifted the resident from their wheelchair and threw them to the bed by pushing their legs with their foot and not even holding their head to prevent them from possibly hitting the wall. Continue on LIC9099C... Continued from LIC9099C... After the demonstration was complete, LPA inquired if they ever use a gait belt for transfers and they replied to no. According to both staff (S1 & S2), neither of them use gait belts nor use the hoyer-lift machine because they don't like it. Based on records review, LPA was provided with a list of residents in care and two assignment sheets dated 7/3/25 with a total of six residents (R2, R3, R4, R5, R6 & R7) that need two-person assistance. Staff training records for both caregivers revealed that staff have received transfer training techniques within the last year. LPA requested the facility’s transfer protocol as well as gait belt procedures, but the Administrative Assistant stated that they don't have one, but they started drafting one to train staff as soon as possible. LPA reviewed R1’s file, which revealed some contradictory information between the register of facility residents (LIC9020 dated 7/1/25 where it describes R1 as ambulatory status. However, the records review of the incident report dated 6/2/25 indicates that on 5/27/25 R1 was found on the floor in their room, after them attempting to transfer themselves from bed to wheelchair and fall. According to the administrative assistant, R1 walks while on a day program, but it is very unsafe when they use their walker, so they need a wheelchair. Although, their physician report (LIC602) needs to be updated to reflect the ambulatory status change. According to R1’s care plan dated 9/29/24, there is an order for a wheelchair as of 7/25/24, their emergency book from placement agency dated 4/11/25 confirmed the use of gait belt needed as an assistive device which needs to be used to help safely transfer or assist with sitting/standing to R1. Furthermore, there is a doctor's order dated 12/20/24 that confirms "daily use of gait belt, walker for home exercise program to tolerance”. However, R1’s care notes about assistance do not indicate the use of gait belt for R1 as prescribed by their doctor. Per administrative assistant, the gait belt is not necessary for R1 because they are able to stand and sit without it. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. **Civil Penalty assessed in total amount of $250.00 for repeated violation within 12 months. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with the Administrative Assistant. Exit interview conducted with the Administrative Assistant via phone and copy of this report was given.