Complaint Investigation Report

Regarding the allegation " facility's plan of operation is not current", it is alleged that it is possible that the caregivers’ room was repurposed into a resident bedroom leading to the staff sleeping in the garage. Administrator stated that the garage and the room near the garage where both licensed as "Administrator Living Area" and she had beds in there because there are times that she and her children sleep in there or staff will ask to sleep in there. LPA reviewed the facility sketch in the Community Care Licensing Department (CCLD) records that was submitted during the application and pre-licensing process and observed that the facility sketch has the garage labeled as “garage” and the room near the garage is labeled as “office”. The pre-licensing visit conducted on 07/19/2019, list a staff room (most likely the office room) and a garage. There is no mentioned of “Administrator Living Area”. During the tour conducted on 07/20/2023, LPA observed bunk beds bunched up together on one side of the garage without any linens and a separate bed with linens and the room that is supposed to be the office was occupied by a resident. During today’s visit, the bunk beds without linens and the separate bed with linens are still in the garage and there is a TV with cable box, a heater, some clothes in a box next to the bed. The office room is vacant and there are some boxes being stored in there. Facility does not have any permits that allows them to use the garage as a living/sleeping area.

Regarding the allegation "facility does not provide a safe environment for the residents in care", it is alleged that there is a step down in the hallway leading from the kitchen area to the garage. The step down is not easily identified, and a piece of tile is missing in the area right below the step down and this could cause a trip hazard. During the tour on 07/20/2023, the LPA observed that as soon as you open the door from the kitchen area there is a hallway that leads to the garage and office room. The floor in the kitchen area is about 3-4 inches higher than the floor in this hallway which creates a step down and can be a tripping hazard. Staff interviewed stated that residents are not allowed to go into this area and that this door needs to be locked. During both tours, the LPA observed that the door was not locked.

Regarding the allegation "facility does not have auditory devices in all exits", it is alleged that there are no alarms on the doors leading to outside. During the tour on 07/20/2023, LPA observed that only the front door has an auditory device. There are 3 exit doors leading to outside that do not have an auditory device which are the back sliding door, the bathroom in bedroom #3, and the exit door in the office room. During today’s visit, all exit doors are missing an auditory device. Facility has dementia resident and are required to have auditory devices on all exit doors.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited and a civil penalty will be issued. Refer to LIC 9099-D and LIC 421IM.