Complaint Investigation Report

Allegation: Staff do not ensure that facility is maintained at a comfortable temperature

for residents. The complaint alleges the air conditioning in residents rooms on the second floor and in the dining room is set too cold and residents complain about being uncomfortably cold. A total of eight residents were interviewed. The majority of the residents interviewed live in the 2nd floor. Three (3) out of eight (8) residents stated the air conditioning in their room was set too low and as a result they were uncomfortably cold. Maintenance staff closed the vents in the room. Per staff interviews, typically the facility temperature is set between 72-74 DF. On 5/23/2025, a physical plant inspection was conducted with Administrator Logan Harrison's assistance. The common areas and dining room were comfortable in temperature. However, 4 out of 7 rooms inspected on the 2nd floor were cold, below 72 DF. Room #207's room temperature measured 62 DF, and rooms 209, 211, and 215 were cold below 72 DF. The findings indicate that room temperature in some of the 2nd floor rooms is controlled by the thermostat in room 207. During today's visit, LPA checked a total of 13 rooms. The temperature in the rooms was within required temperature range. However, there is sufficient evidence to support the allegation.

Allegation: Staff do not ensure the facility is free of tripping hazards. It is alleged that a resident fell in the dining room because of uneven flooring. Three (3) out of eight (8) residents confirmed R2 fell in the dining room. Staff interviews confirmed that on April 29, 2025, at approximately 12:30 PM, resident (R2) fell while dancing and walking in the dining room. The incident resulted in a femur fracture and surgery. Staff confirmed some areas in the dining room have peeling laminate flooring. Based on physical plant observations on 5/23/25 and today, the findings indicate the center left flooring in the dining room has a section of raised laminate flooring of approximately 7 inches that poses a tripping hazard. Pictures were taken during the visits. As of today, the flooring has not been repaired. Interim Administrator stated contractors will be coming to the facility in the next couple of weeks to evaluate the flooring issue and determine a repair plan. There is sufficient evidence to support the allegation.

Based on observation and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Pursuant to Title 22, California Code of Regulations, a deficiency was cited.

An exit interview conducted, copy of the report and appeal rights was provided to Interim Executive Director Mario Preston.