complaint·November 5, 2024

(continued from LIC9099, page 1) Regarding the allegation: “Licensee does not have sufficient staff to meet the care needs of residents” LPA had investigated this same allegation under complaint control number 29-AS-20230918110909. On 3/8/2024, LPA had reviewed the staff schedule for caregivers and medication technicians. LPA went over concerns with the administrator Rick Olds, including no medication technicians on the schedule for Sundays and Thursdays during the NOC shift (10:00 p.m. - 6:15 a.m.). The administrator confirmed they have had some issues finding qualified staff to fill these time slots and on 3/7/2024, they did not have a medication technician during the NOC shift. Based on this information, this allegation is deemed Substantiated. Note: The same allegation was addressed and substantiated under complaint control number 29-AS-20230918110909 which covers the same time frame of this complaint. Regarding the allegations: “Facility staff do not ensure residents toileting needs are met in a timely manner” and “Facility staff do not ensure adequate supervision is provided to residents in care” LPAs had conducted prior investigation visits to the facility on 9/18/2023, 9/25/2023, 12/12/2023, and 3/8/2024 for complaint control number 29-AS-20230918110909. Based on interviews with staff, residents were complaining to them about long wait times to receive assistance, including toileting assistance, from staff. Staff stated due to lack of staffing, residents were not being assisted in a timely manner. Interviews with residents indicated the same issue. Based on interviews, these allegations are deemed Substantiated. Note: These allegations were encompassed under complaint control number 29-AS-20230918110909 which were addressed and substantiated; this complaint covers the same time frame. Regarding the allegation: “Staff allowed resident to leave the facility unattended”. LPA conducted interviews with staff who confirmed that resident 1 (R1) would usually wait outside in the front of the building or inside the lobby for their daughter to pick them up. On 08/21/2023, R1 was waiting in front for their daughter to take them to a dentist appointment scheduled for 3:00 p.m. The dentist is across the parking lot from the facility. Apparently, R1 decided to meet their daughter at the dentist and left the facility in their wheelchair to the dentist. R1’s daughter discovered R1 had left the facility unattended when they arrived at the facility. Although R1 had no cognitive dysfunction, R1’s physician’s report indicated R1 required assistance when leaving the facility. The facility did report this incident to CCL. Based on this information, the allegation is deemed Substantiated at this time. (continued on LIC9099C, page 3) (continued from LIC9099C, page 2) Regarding the allegation: “Facility staff do not ensure reporting requirements are followed” LPA reviewed documentation regarding reported incidents involving R1. The complaint alleged R1’s incidents were not being reported to R1’s responsible party. LPA found a facility internal incident report dated 8/3/2022 involving R1 which had no indication on the report it was reported to R1’s responsible party. Based on this information, the allegation is deemed Substantiated at this time. Regarding the allegation: “Facility staff was asleep while at work.” LPA conducted interviews with staff. It was confirmed that at least one staff (S1) was found asleep during the NOC shift in the common area of the memory care unit. S1 was counseled and written up. Based on this information, this allegation is deemed Substantiated at this time. Regarding the allegation: “Licensee does not ensure staff are properly trained to care for residents” LPA had investigated a similar allegation under complaint control number 29-AS-20230918110909. On 3/8/2024, LPA had reviewed the staff schedule for caregivers and medication technicians. LPA went over concerns with the administrator, including no medication technicians on the schedule for Sundays and Thursdays during the NOC shift (10:00 p.m. - 6:15 a.m.). This complaint was regarding caregivers not receiving proper training for oxygen administration. The administrator Rick Olds stated all medication technicians and some caregivers receive that training. During the time of this complaint, medication technicians were not always at the facility and it was possible some caregivers may not have had training for oxygen administration. Based on this information, this allegation is deemed Substantiated at this time. The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.