Complaint Investigation Report

showing face masks were provided to clients, training documents for the medication technicians; facility monthly menu. LPA/RA Ceniceros toured the facility's dining room, common bathrooms, and the commercial-size kitchen.)

Regarding Allegation #1 : this investigation revealed that the housekeepers and/or kitchen staff clean the dining room area floors - following meals and housekeeping maintains the floors in the clients' rooms. (LPA/RA Ceniceros toured the facility and observed the floors to be clean.) Facility staff and clients interviewed corroborated that housekeeping does a very good job of maintaining the facility's cleanliness including the clients rooms. LPA/RA Ceniceros toured the common bathrooms and observed them to be sanitary including the floors and walls were clean.

Based on the observation and interviews conducted, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PHYSICAL PLANT: Facility is unclean is found to be UNSUBSTANTIATED.

Regarding Allegation #2 : this investigation revealed that the facility serves the clients a three (3) course meal: Breakfast is served between 7:30 a.m. - 9:00 a.m.; lunch is served between 12:00 noon - 1:00 p.m.; Dinner is served between 4:00 p.m. - 5:30 p.m. (LPA/RA observed the clients sitting in the dining area eating their breakfast upon arrival to the facility. LPA/RA toured the facility's commercial-size kitchen and observed a posted menu and perishable and non-perishable food supply. LPA/RA reviewed the facility's monthly menu that documented the meals served to clients that also includes snacks.) Facility staff and clients interviewed corroborated that the food service at the facility is adequate and if a client does not like something on the menu that the facility does serve an alternate meal.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of FOOD SERVICE: Inadequate food service is found to be UNSUBSTANTIATED.

Regarding Allegation #3 : this investigation revealed that facility staff receives in-service training annually. A review of the medication technicians training records documented medication verification training on 01/22/20, 11/19/21, 01/12/22, 05/12/22 on the topics of administering medications and document in the medication administration record, shadow destruction, receiving home health services, COVID-19 screening procedures,