Complaint Investigation Report

Allegation: Staff failed to provide a comfortable environment for residents in care. It is alleged that on Sunday, April 23, 2023 at approximately 6:30 PM, the facility water supply was shut off. Residents did not receive notification of the reason for the water shut off because allegedly facility staff do not speak and/or are not able to communicate with residents in their Asian language. Facility staff in charge on the premises at the time of the incident were the security guard and med-tech staff. Per staff interviews, room #230's bathtub plumbing fixture could not be turned off. Maintenance staff was called and it directed the security guard to shut off all of the building water supply. Maintenance staff immediately returned to the facility and fixed the issue. Some residents were informed that the water would likely be restored until the following morning and were not able to provide emergency guidance or plan procedures. Other residents and their families were not notified of the issue. Interim Administrator stated it had no knowledge of the plumbing water incident that occurred. The findings indicate that facility staff on duty during the incident did not follow emergency policy procedure notification to residents and their responsible parties. The incident was resolved a couple of hours later.

Allegation: Facility does not have an Administrator. It is alleged that the facility has not had an Administrator since February 2023 because the Administrator has been on a leave of absence. The two staff in charge are the Wellness Nurse and Administrative Assistant and neither staff are certified Administrators. It is alleged that it is unclear whom is in charge of facility operations because families have not received notification of Administrator changes and Administrator Chia Demurjian has not responded to phone calls of emails. According to staff interviews, Administrator Ms. Demurjian has been on leave since February 17, 2023. Interim Administrator Ms. Nelida Arlante stated that she began working at this facility and the Skilled Nursing Facility (SNF) next door on February 1, 2023. However, on 3/24/2023 LPA visited the facility and an Administrator had not been appointed, nor was CCL notified of the Administrator changes. On 3/31/2023, facility staff submitted an incomplete change of Administrator document packet. As a result the Administrator on record has not been changed. Ms. Arlante confirmed she does not have an office at the facility and only makes quick rounds at the facility. Therefore, the Interim Administrator appointed is not on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility. Per staff interviews, the Licensee asked the Wellness Nurse and Administrative Assistant to take RCFE Administrator education classes, but neither staff is yet certified and/or may not meet the qualification requirements. A total of six (6) residents were interviewed none of the residents are are that Ms. Nelida Arlante has been appointed the Interim Administrator. Two (2) out of the six (6) residents stated they think Administrative Assistant Sau Lee is the Administrator.