complaint·December 12, 2024

The investigation also determined that the facility failed to notify the Community Care Licensing Division of R1’s hospitalization, as required by regulations. As a result of these failures, R1’s medical care was delayed, leading to their hospitalization for conditions that could have been addressed sooner with timely intervention. R1 remained in the hospital until December 2, 2023, after which they were discharged to a skilled nursing facility. The facility has a meal log that documents the approximate amount of food eaten per meal. It shows a decline in the amount of food the resident was consuming three days prior to the resident being sent out to the hospital. Facility also did not report to Community Care Licensing Division that the resident was sent to the hospital due to decline. Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met that the facility failed to seek timely medical care, notify the physician, and the Department that resident’s health was in decline. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency and civil penalty are being issued An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted. Staff did not seek medical attention for resident in care in a timely manner. Appeals rights issued. The Department investigated an allegation that staff at the facility were not adequately trained. The investigation focused on the period from the facility’s opening to November 2023. A review of staff training records revealed that, during this time, two staff members had only completed the initial required training under Title 22 regulations and the California Health and Safety Code in 2021, with no evidence of the mandatory annual training. Additionally, one staff member had no training documented. A deficiency related to this issue was cited during a case management visit on November 22, 2023. Following the citation, the licensee took corrective action, and as of November 2023, all staff have completed the required training in compliance with Title 22 regulations and the California Health and Safety Code. As the licensee addressed the prior deficiency, the current allegation is substantiated , but no additional deficiency is being issued. The administrator denied the presence of a staff member by the alleged name working at the facility. Additionally, the licensee and administrator both stated they were not informed of any incidents of staff abusing R1. The department attempted to identify the caregiver accused of the abuse but was unable to verify the identity of the individual. Interviews with a second staff member and other residents present during the time frame provided no corroboration of the abuse. One resident declined to participate in the interview process. The department reviewed all available information, including conflicting statements from the involved parties. Due to the inability to verify the identity of the alleged caregiver, corroborate the abuse claims, or obtain additional evidence, the department is unable to substantiate or refute the allegation therefore the above allegation is unsubstantiated. The Department conducted an investigation into the allegation that staff failed to ensure R1’s grooming needs were met while in care. As part of the investigation, the Department conducted interviews with residents and staff. Unfortunately, Resident 1 (R1) could not be interviewed or observed regarding their grooming care, as R1 had passed away before the investigation. Staff members interviewed denied the allegation, asserting that R1’s grooming needs, including nail care, had been appropriately addressed. The allegation included claims that R1’s toenails were not maintained and that a witness had to provide nail care for R1. However, during observations of other residents in care, there were no indications of neglect or unmet grooming needs. Based on the available evidence, the Department did not find corroboration of the alleged failure to meet grooming standards. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated . The Department investigated an allegation that staff failed to ensure Resident 1 (R1) received their medications as prescribed. As part of the investigation, the Department obtained and reviewed R1’s medication administration records (MARs). The records indicated that medications were administered as prescribed while R1 was at the facility. Staff reported that on the R1’s final day at the facility, R1 refused to take their medication. The Department was unable to verify the condition of the medication containers, as they were no longer at the facility at the time of the investigation. The allegation also included claims that the medication bottles were either full or contained an excessive number of pills when R1 moved out. However, without access to the medication containers during the investigation, the Department could not confirm this claim. Based on the evidence available, the Department was unable to substantiate or refute the allegation that R1 was not provided their medications as prescribed. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. The Department investigated an allegation that staff at the facility were unable to communicate effectively with R1 due to a language barrier, potentially impacting the quality of care. It was alleged on November 21, 2023, R1 was feeling unwell required assistance from staff and that the resident’s condition had been worsening over several days, yet staff failed to take appropriate action. It was further alleged that a primary caregiver’s inability to speak English contributed to the lack of care provided. Based on a review of staff records and interviews conducted with residents, the Licensee, the Administrator, and staff working during the specified time frame it was discovered that there were several caregivers with limited English proficiency. However, the investigation was unable to substantiate whether the language barrier directly interfered with the care provided to R1. Based on the evidence gathered, the Department finds that the allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated . 2. The Department conducted an investigation into the allegation. The investigation included a review of R1’s medical records, hospital records, and interviews with relevant parties. Based on a review of the medical and hospital records, there was no documentation or indication in these records that R1 was dehydrated upon admission or during care. Interviews conducted during the investigation included staff members, facility management, and other relevant parties. A witness stated that R1 appeared severely dehydrated on the day they were sent to the hospital. However, the facility staff denied this claim, indicating that R1’s condition was regularly monitored, and no signs of severe dehydration were observed prior to the transfer. The Department noted that the accounts provided during interviews were inconsistent. The witness’ assertion of severe dehydration conflicts with the medical documentation reviewed, which did not support this claim. Based on the evidence gathered, the Department finds that the allegation is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. 3. The Department investigated an allegation that the Licensee accepted a resident whose care needs exceeded the level of care the facility could provide during the time frame from the facility’s opening to November 2023. Based on the investigation, the Department reviewed R1’s file, including the pre-admission appraisal. Pre-placement admission appraisal indicated that R1 was able to walk with a walker, able to eat with minimal assistance and supervision, required assistance with showering and using the bathroom, assistance with preparing medication and supervision when taking medication, and required a special diet. Based on the documentation at the time of admission, R1 was assessed to require assistance that fell within the facility’s capabilities under Title 22 Regulations. Based on the evidence gathered, the Department finds that the allegation is unfounded . A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.