Complaint·October 27, 2023

Regarding the allegation, Resident not being treated with dignity and respect, it was alleged that on 08/20/2023, Staff #1 (S1) told Resident #1 (R1) that they were trying to fall to sue the facility. It was further alleged that R1 reported the incident to S2 and S2 reported the incident to management. The LPA observed that the Administrator had submitted an Unusual Incident Report (UIR) to document the above-mentioned interaction and/or incident. After review of the incident, on 08/28/23 the Administrator informed the LPA that they were in the process of reviewing the event. During the investigation, a written charting note made by S1 regarding the incident was provided to the LPA. S1 wrote that R1 had approached them and requested for R1’s walls to be checked for leaks, and no leakage was found. Later R1 had gone outside as they were “concerned about the downspout flooding outside”. S1 stated that they requested R1 to go back inside, which they did, and R1 later went back outside. S1 wrote they told R1 “maybe you are trying to hurt yourself here, so you can sue the home,” after they had requested for R1 to come inside again. Additionally, Licensing Program Manager KaSandra Lopez conducted a telephone interview with S1 on March 13, 2024. Based on record review, and interviews there is sufficient evidence to support the allegation that Resident not being treated with dignity and respect. The allegation is deemed Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted and copy of the report and appeal rights provided to HOR2 Cindy Gambill. Regarding the allegation, Staff threatened resident, it was alleged that on 08/20/2023 S1 threatened R1 to go inside their room or that they would contact the sheriff. It was further alleged that R1 reported the incident to S2 and S2 reported the incident to management. The LPA observed that the Administrator had submitted a Special Incident Report (SIR) to document the above-mentioned interaction and/or incident. To investigate the allegation, the LPA reviewed pertinent documents, and conducted resident and staff interviews. Interviews and record review revealed that S1 told R1 “if you don’t follow my directions, I’m going to call the Sheriffs.” However, interviews with S1 and R1 revealed that S1 had told R1 to step away from blocked off areas due to water leaking multiple times, and R1 had been asked to go inside their room multiple times due to safety concerns due to the hurricane and heavy rain on that day. Interview with one witness (W1) revealed that even though S1 did tell R1 to go inside their room or they would contact the sheriff, it was due to safety concerns. Lastly, all additional residents interviewed revealed that they feel safe and have no concerns regarding S1. Based on the information gathered on the above allegation, although the allegation may have happened or is valid, there was insufficient evidence to confirm that “Staff threatened resident”. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.