Complaint Investigation Report

Based on interviews conducted the statements obtained were consistent and corroborated with the allegation. Residents and staff interviewed confirmed that the fire doors that exit to the back patio (where residents take breaks) are too heavy for residents in wheelchairs to open. Often times, residents will wait on staff to come and open the doors for them because they are unable to keep the door open and wheel themselves out at the same time. During today's visit, LPA tried opening the fire doors that exit to the back patio and observed the weight of the doors and based on LPA's observation, it would be very difficult for anyone in a wheel chair to hold the door open and wheel themselves out at the same time.

Based on interviews conducted and LPA's observation, there is sufficient evidence to support this allegation to be true.

Allegation: Residents soiled linen is not changed timely. Based on interviews conducted, the majority of statements obtained were consistent and corroborated with the allegation. Residents confirmed that linens and bed sheets are not changed regularly and often times residents have to request for their linens to be washed/changed because staff will not change them. There have been times where residents linens and bed sheets have not been changed for more than two weeks. During today's visit, LPA toured a random selection of resident rooms and observed the linens in rooms 33, 34B, 38B and 36B were soiled/dirty. Blood stains were observed on the linens in rooms 34B and 38B and on the pillow case in room 33. The pillow case in room 36B was torn and covered in stains. Based on majority of the interviews conducted and LPA's observation, there is sufficient evidence to support this allegation to be true.

Based on LPA’s observations and interviews which were 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 & Chapter number), are being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of this report was provided to the Assistant Administrator along with the Appeals Rights.