Complaint Investigation Report

LPA Moleski reviewed this facility's file. LPA Moleski reviewed this facility's fire clearance, dated 1/22/19. The fire clearance states that "the two rooms in the garage shall only be used for storage and are not approved for habitable living space." Nonu said over the phone that S1 had been living in the garage. S1 confirmed that S1 was living in the garage and showed LPA Moleski S1's room, which is one of the rooms identified on the facility sketch as not being cleared for habitable living space.

In an interview, LPA Moleski asked S1 about night staffing. S1 said that S1 is the only staff member present at night. S1 said she sleeps in her bed in the garage throughout the night, but said that she wakes up when she hears door alarms and redirects residents inside. 22 CCR Section 87415 states that there shall be an on-call staff available during the night to supervise residents, and that staff " shall be available ... to assist in caring for residents in the event of an emergency. " S1's room in the garage is separated from the main area of the facility by three doors and a laundry room, and S1 would not be able to hear a resident calling for help from their room while asleep in the garage. Additionally, as the laundry room was observed to contain cleaning solutions during this visit, the door to the laundry room must remain locked at all times. The door to the laundry room is the only interior passage to the garage in the facility. S1 confirmed that the laundry room door is locked during the night, although S1 said that residents do knock at the laundry room door at night. R6's LIC 602, dated 11/22/23, indicates that R6 is not able to independently transfer to and from bed, meaning that R6 is not able to seek out assistance from S1 during the night.

LPA Moleski reviewed six residents' LIC 603s. R1's LIC 603, dated 2/2/23, indicates that R1 needs overnight supervision. 22 CCR Section 87705 states that " a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. " R1 has dementia, according to R1's LIC 602, dated 9/21/23. S1 said that R2 wanders frequently throughout the night and needs to be checked on often. R2's LIC 602, dated 2/8/24, indicates that R2 has dementia and schizophrenia.

The department has determined the following as it relates to the allegations that staff are residing in garage without clearance and that there is insufficient staff at the facility: