complaint·May 24, 2024

(2nd page continued...) On 05/23/2024, LPA Cortez toured the facility, interviewed two (2) residents, and one (1) staff, observed residents at lunch, conducted a file review and obtained pertinent documents. During today's visit, LPA Cortez conducted a medication audit, toured the facility and interviewed staff. Staff sexually abused residents On the allegation that Staff sexually abused residents; it is the concern of the reporting party that Staff#1 (S1) has been sexually abusing residents for decades. To investigate the allegations LPA Cortez conducted interviews and physical tours of the facility. Staff and residents were interviewed on 04/10/2023, 07/28/2023, 02/16/2024, and 05/23/2024. LPA Smith interview former staff on 07/27/2023 and LPA Cortez also interviewed residents TCRC Service Coordinators (SC). Interviews conducted with staff revealed that staff did not have any concerns or knowledge of sexual abuse occurring at the facility. Interviews with S1 revealed that S1 was consistently working at the facility for about four to five months in 2022 and now only visits the facility one to two times a year and denied ever abusing any of the residents in any form. In addition, S1 stated that their interactions with the residents was mainly checking in on them and making sure they were fine, and that the facility has a zero tolerance for abuse. Staff interviews revealed that S1 was very nice to the residents, and that S1 has never been seen mistreat the residents. Furthermore, all staff interviewed regarding the above allegation stated that any abuse would be reported. Interviews conducted with the residents revealed that staff treats residents well, and residents did not voice any concerns of sexual abuse. Interviews conducted with TCRC SC revealed that almost all the residents have a service coordinator who visits them once every three months and provide services depending on the resident. Services can range from crisis support, funding, and supplemental support among other services. Five of six service coordinators interviewed revealed that they have no concerns regarding the residents at the facility and that the residents are doing well. One of six service coordinators interviewed revealed that there have been previous concerns in the past, those concerns have been addressed with staff, and the concerns voiced were not related to sexual abuse. On 04/10/2023, 02/16/2024 LPA Cortez toured the facility and did not observe any health or safety concerns. Report will continue on LIC9099-C (3rd page) . (3rd page continued...) On 05/24/2024 LPA Cortez toured the physical plant and observed all sixteen (16) residents either sleeping, watching TV, on the phone or interacting with one another and did not observe any health or safety concerns. No concerns were voiced during today’s visit. Based on the investigation, there is insufficient evidence to support the claim that Staff sexually abused residents. This allegation is deemed Unsubstantiated at this time. Facility illegally evicted residents. On the allegation that Facility illegally evicted residents ; it is the concern of the reporting party that residents are being wrongly evicted out of the home and that residents that had Covid-19 are being put on the streets to die. RP did not provide any information as to which residents have been evicted from the facility. To investigate the allegation interviews were conducted with staff, current administrator and two (2) former administrators. LPA Smith conducted an interview with the current administrator on 07/28/2024. Interview conducted with the Administrator revealed that they have not had to issue any evictions during their time here at the facility and has not heard anything about any illegal evictions. Interviews conducted with former administrators revealed that during their time at the facility they did not have to serve any eviction notices. Interviews also revealed that staff have eviction protocols which includes serving the residents with a 30-day notice and sending it to licensing for approval before serving it to the residents. Furthermore, interviews revealed that staff tries to work with the resident to make sure the resident do not end up homeless. Four of four staff that were asked regarding the above allegation revealed that they have not seen any residents being evicted or have not heard of residents being evicted. Based on the investigation, there is insufficient evidence to support the claim that Facility illegally evicted residents. This allegation is deemed Unsubstantiated at this time. Report will continue on LIC9099-C (4th page). (4th page continued...) Facility not safeguarding residents personal belongings. On the allegation that Facility is not safeguarding residents’ personal belongings; it is the concern of the reporting party that resident’s money, medication, and belongings are being stolen. To investigate the allegations resident and staff interviews and file reviews were conducted by LPA Cortez and LPA Smith. LPA Cortez also conducted interviews with resident’s service coordinators from TCRC. Lastly during today’s visit, LPA Cortez conducted a medication audit for five (5) residents. All resident interviews conducted regarding the above allegation revealed that they have not had anything go missing or stolen from their rooms. All Interviews conducted with staff revealed that they were not aware of any issues or concerns of any stolen items. Administrator’s interview revealed that they or staff do not touch any of the resident’s money. For residents who do not receive services through TCRC, the administrator will purchase anything necessary for them with the money provided by the facility and then the resident’s family will reimburse the administrator. Furthermore, for the residents with TCRC, they have a process in place where the resident's funds are managed by the facility’s corporate office accounting staff alongside Trust Management Services (TMS) provided by TCRC. Anytime a resident wants to purchase something the money is given to them and the resident signs receipt for the amount given. If there’s a particular item that the resident wants to make online, the administrator will assist the resident with the purchase and will save copy of the receipt. Administrator interview and file review revealed that the administrator keeps records of all transactions and receipts and sends out to accounting for reimbursements. Interviews conducted with TCRC SC revealed that almost all the residents have a service coordinator who visits them once every three months and provide services depending on the resident. Services can range from crisis support, funding, and supplemental support among other services. Six (6) of six (6) service coordinators interviewed revealed that residents’ funds are managed by TMS and have no concerns regarding the residents’ finances. During the Med audit conducted today for five (5) of sixteen (16) residents, the LPA observed medications centrally stored and locked in a medication cart; medications are labeled and checked for expiration dates. All medications were accounted for. The LPA interviewed the Assistant Administrator (AA) during the med audit. Interview with the AA revealed that there is only two (2) sets of keys to the med cart, and only the med techs, administrator and assistant administrator have access to those keys. If any individual from corporate would want to access the Med cart they would need to ask staff, and that has not happened to their knowledge. In addition, Med audit and file review revealed that MT's conduct a Narcotic count at the beginning and the end of their shift. Report will continue on LIC9099-C (5th page) . (5th page continued...) Based on the investigation, there is insufficient evidence to support the claim that facility is not safeguarding residents’ personal belongings. This allegation is deemed Unsubstantiated at this time. Facility denied food to residents. On the allegation that residents are denied food, the RP only stated that residents are being denied food. To investigate the allegation staff and residents were interviewed, and on 05/23/2024, LPA Cortez observed lunch time at approximately 12:00 p.m. The LPA observed approximately twelve (12) residents in the dining room, either eating on their own or residents were being fed by staff. The LPA also observed care staff requesting kitchen staff meals to be deliver to residents in their room who were not going to eat at the dining room. At approximately 12:10 p.m. the LPA observed two (2) residents asking for more food, which was provided to them. One of the two residents continue to ask for more food approximately two to three more times, which was provided to them. Per the staff interviews, four (4) of the residents were served in their room due to not feeling well. Five out of five residents interviewed throughout the investigation regarding this allegation revealed that the facility provides meals and snacks. One (1) of four (4) residents stated that the facility food was good and that they even got extras. Ten (10) of ten (10) Staff interviews conducted regarding this allegation revealed that staff have never denied food to the resident. Eight (8) of ten (10) staff revealed that they have no knowledge of any staff denying food to residents. Two (2) of ten (10) staff interviewed revealed that there has been concerns about staff denying food to residents, however those concerns were addressed by the administrator or themselves. Based on the information received through interviews, and observation, there is insufficient evidence to support the claim Facility denied food to residents. Therefore, this allegation is deemed Unsubstantiated at this time. Report will continue on LIC9099-C (6th page). (6th page continued...) Residents are threatened while in care and Residents are bullied while in care. On the allegations that Residents are threatened while in care and Residents are bullied while in care; it is the concern of the reporting party that residents are being threatened with bodily harm and financial abuse if they complain to licensing and are bullied. To investigate the allegations LPA Cortez and LPA Smith conducted interviews and physical tours of the facility. Staff and residents were interviewed on 04/10/2023, 07/28/2023, 02/16/2024, 05/23/2024 and 05/24/2024. LPA Smith interview former staff on 07/27/2023 and LPA Cortez also interviewed resident TCRC service coordinators (SC). Six (6) of eight (8) staff, including former staff, interviewed regarding of the above allegation stated that they have no knowledge of any mistreatment occurring at the facility. Two (2) of eight (8) staff stated that there have been concerns of mistreatment, however that those concerns were reported to CCL and addressed. Furthermore, all staff interviews regarding the above allegation stated that any abuse would be reported, and all staff denied threatening or bullying residents and that residents have not voiced any concerns to them. Interviews conducted with the residents revealed that staff treats residents well, and residents feel safe at the facility, and they have no concerns regarding the above allegations. Interviews conducted with TCRC SC revealed that almost all the residents have a service coordinator who visits them once every three months and provide services depending on the resident. Services can range from crisis support, funding, and supplemental support among other services. Five (5) of six (6) service coordinators interviewed revealed that they have no concerns regarding the residents and that the residents are doing well at the facility. One of six service coordinators revealed that there have been previous concerns in the past, however those concerns have been addressed by the administrator and were not regarding the the resident being threatened or bullied. On 04/10/2023, 02/16/2024, 05/23/2024 LPA Cortez toured the facility and did not observe any health or safety concerns. During today’s visit the LPA toured the physical plant and observed all sixteen (16) residents either sleeping, watching TV, on the phone, or interacting with one another. No concerns were voiced during today’s visit. Based on the investigation, there is insufficient evidence to support the claims that Residents are threatened while in care and Residents are bullied while in care. These allegations are deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. A copy of the report was issued.