Complaint Investigation Report
The investigation revealed the following:
Allegation: Facility is not adequately staffed.
On 12/12/2023, LPA interviewed two staff (S1-S2). Interviews with S1 and S2 revealed there are two caregivers providing care and supervision to five residents during day shift from 7:00 AM through 7:00 PM. S1 and S2 stated an awake staff is placed to work overtime when any residents pose a restless behavior. Based on interview with S1 and S2 and LPA's records review, it was revealed that four residents (R1, R2, R4 & R5) need close supervision due to their medical conditions, however S1 and S2 stated there are no awake staff during night shift. Based on LPA's observations, R5 was not present during the visit. LPA observed R1 is ambulatory and uses a walker. LPA observed R2 is bed bound and R4 walks around the facility with a walker. Based on LPA’s review of records R1 is confused, has wondering behavior and unable to leave the facility unassisted. R1’s appraisal indicates R1 is a fall risk and needs adequate supervision for safety. Based on review of the appraisals, R2 and and R4 need special observation/night supervision. R5’s appraisal show R5 has memory loss and needs adequate assistance to promote safety. Based on observations, interviews, and records review there is enough evidence to prove that above allegation is corroborated.
Allegation: Facility failed to maintain a complete and accurate resident’s records.
On 12/12/2023, LPA interviewed two staff (S1-S2). Interviews with S1 and S2 revealed they assumed the resident records are maintained completely and accurately. LPA reviewed records of five out of five residents (R1-R5). LPA’s records review revealed resident records are not maintained completely and accurately. LPA observed R1’s file has no current medical assessment, no weight records, no accurate appraisal, and no completed cash resources. R2’s file has no medical assessment, no weight records, no immunization records, no TB test record, no completed safeguard for cash resources and for property and/or valuables. R3 has no weight records, no completed safeguard for cash resources and
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction