Complaint Investigation Report

On 04/11/2022, the Department received a complaint regarding allegations of Neglect/Lack of Supervision. It was alleged that the facility staff failed to obtain timely medical care for Resident #1 (R1). It was reported that on 04/08/2022 the overnight (NOC) shift witnessed R1 with a nosebleed and a bruise to left eye, yet R1 was not transported to a medical facility until 1:00 p.m. later that day. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Olivia Spindola.

On 04/12/2022, between 10:15 a.m. and 2:15 p.m., LPA Campos conducted the initial 10-day complaint visit. The LPA met with the Administrator Eileen Esquivel and explained the reason for the visit. During the visit there were ten (10) staff and thirteen (13) residents present. The LPA reviewed records and obtained pertinent copies of documents at 11:00 a.m. and 1:40 p.m. From 10:25 a.m. to 12:10 p.m., the LPA conducted a physical plant tour with the Administrator and interviewed staff. The Administrator was notified that the complaint was referred to the Community Care Licensing Investigation's Branch (IB) and assigned to Investigator Olivia Spindola.

On 04/16/2022, LPAs Campos and Ashley Smith conducted an unannounced subsequent complaint visit. The LPAs met with Business Office Manager Megan Cordova and explained the reason for the visit. During the visit, the LPAs conducted a physical plant tour at 1:20 p.m., conducted a file review at 11:00 a.m. and interviewed staff from 11:50 a.m. to 3:49 p.m. The LPAs noted further investigation was required.

Investigator Spindola conducted interviews with the facility Health Services Director on 05/03/2022, at approximately 11:00 a.m.; with the facility Executive Director/Administrator at approximately 12:10 p.m.; with facility caregiver at approximately 12:45 p.m.; with the facility Environmental Services Director at approximately 1:30 p.m.; with a facility resident at approximately 1:50 p.m.; on 05/12/2022 and 06/28/2022 left voice messages for R1’s representative; with R1’s representative on 07/06/2022 at 9:00 a.m.; with facility staff on 07/07/2022 from approximately 12:00 p.m. to 12:30 p.m.; and with facility staff on 07/08/2022 from approximately 10:30 a.m. to 11:30 a.m. Additionally, Investigator Spindola reviewed copies of R1’s facility records, medical records and photos of R1’s injuries.