complaint·March 14, 2022

Allegation: Resident is left on couch for extended period, not given meals, not having their adult diaper changed. - SUBSTANTIATED. Review of documents revealed that the administrator issued a written warning to S1 that stated S1 was locked in the office and R1 was left on the couch, had not been fed or changed since S1 arrived on shift. This written warning was signed and acknowledged by S1. A text message that was sent to the administrator on February 5 at 6:25 PM states “S1 is hiding in the office… R1 hasn’t had dinner and has been sitting on the couch the entire day!” A subsequent text message sent from the administrator to S1 on February 5 at 6:32 PM states “It’s time you came out of the office… I don’t think R1 has had dinner or been changed since you got there.” A text message on February 5 at 7:31 PM from the administrator states “Did S1 come out?” to which the reply was “Yeah finally fed her.” During document review it was learned that R1 has a diagnosis of dementia and requires assistance with personal activities of daily living. During interview of administrator it was learned that on 2/05/2022 S1 filled in for staff who had called off and worked the evening shift from 4:45 PM - 11:45 PM. The administrator was notified that S1 was hiding in the office and R1 had not been fed. The administrator called S2 and they went to the facility and told S1 that they needed to work. The administrator texted S1 at 6:30 PM and told S1 they better come out of the office, feed R1 and change R1. S1 got R1 up at 6:30 PM and gave R1 dinner. At 7:30 PM administrator received confirmation that, S1 had come out of the office and fed R1. S2 had placed R1 on the couch at about 2:30 PM that day. R1 had lunch and then snack at 2:30 PM. S2 had changed R1's adult diaper at 4:15 PM before they went home and then put R1 back on the couch. S1 changed R1's adult diaper after R1 had dinner at 6:30 PM. During resident interviews it was learned that on more than one occasion S1 has locked themselves in the office. Staff interviews confirmed that S1 had left R1 on the couch unattended, did not change R1’s adult diaper and did not feed R1 any meals or snacks during the time period that S1 was locked in the office. Continued on LIC9099-C Allegation: Staff person locks themselves in the office and tells residents to go away when they ask for assistance. - SUBSTANTIATED. Review of documents revealed that the administrator issued a written warning to S1 that stated S1 was locked in the office and R1 was left on the couch, had not been fed or changed since S1 arrived on shift. This written warning was signed and acknowledged by S1. A subsequent text message sent from the administrator to S1 on February 5 at 6:32 PM states “It’s time you came out of the office… I don’t think R1 has had dinner or been changed since you got there.” During interview of administrator it was learned that on 2/05/2022 S1 filled in for staff who had called off and worked the evening shift from 4:45 PM - 11:45 PM, The administrator was notified that S1 was hiding in the office and R1 had not been fed. The administrator texted S1 at 6:30 PM and told S1 they better come out of the office, feed R1 and change R1. During resident interviews it was learned that on more than one occasion S1 has locked themselves in the office. Staff interviews confirmed that S1 had locked themselves in the office. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was emailed to the administrator Julie Wilcox. Continued on LIC9099D