complaint·December 26, 2024

Additional staff promptly arrived to assist including 2 other care staff, the business manager and the Health and Wellness Director. Due to the fact that the event was appropriately staffed and resident behaviors can be highly unpredictable the allegation of "staff did not prevent a resident from dragging another resident" is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened the preponderance of evidence does not prove it. Since this incident the facility has called a care conference with the family of R3 and are working with R3's physician to determine if medication adjustments are in order. An exit interview was conducted a copy of this report was given. A staff member from an outside agency reported their client has been receiving their meals late. A responsible party stated that their family member has 2-3 altercations with another resident. A different responsible party stated that their family sustained fracture to the spine and hit their head as a result of staff not being adequately trained. Based on records reviewed and interviews conducted with current staff, former staff, outside agency staff and family members the allegation of "staff is unable to meet the needs of the residents while in care" is SUBSTANTIATED. A finding of substantiated means the preponderance of evidence standard has been met. The consensus amongst interviewees is that the facility was understaffed for a period of time which resulted in residents not receiving adequate care and supervision. Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report and appeal rights was provided.