Complaint Investigation Report

Interviews with Administrator and staff revealed that fire drills have not been conducted. Facility could not provide the LPA with previous documented fire drills. During today's visit, Administrator told the LPA that they conducted a fire drill on 09/22/2023 (a day after the LPA's first visit) and provided documentation of that fire drill. Clients interviewed corroborated the allegation.

Regarding the allegation "staff do not report incidents to appropriate parties”, it is alleged that staff do not send special incident reports regarding residents missing their medications or residents refusing to take medications. Interviews with Administrator and staff revealed that they were unaware that they needed to report this type of incidents to Community Care Licensing Division (CCLD). During today's visit, Administrator told LPA that they have already begun submitting incident reports to CCLD since the LPA's last visit and provided the LPA copies of incident reports for the last 2 months.

Based on LPA's interviews, records reviewed and observations, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 1 are being cited on the attached LIC 9099-D.

Exit interview held and a copy of the report and appeal rights was provided.