Complaint Investigation Report

LPA Valerio reviewed facility files for Staff 1 (S1). LPA observed completed training certificates for the following topics: Medication training - 01/10/2024, Dementia Care Staff Training - 02/02/2024, Osha training - 01/20/2024, 40 hour orientation training - completed, Oxygen training - 02/01/24, Orientation training - 01/18/24 - 02/01/2024, and Disaster and Emergency Training - 02/01/2024. All training were instructed by Administrator Beatrice.

On 11/26/2024, LPA Valerio observed Staff 3 (S3) working at the facility. Licensee/Administrator Beatrice was cited for California Code of Regulations (CCR) Title 22, Section 87411(g)(2) for not obtaining a fingerprint clearance for S3 prior to working at the facility. According to an interview with S3, S3 was there shadowing the main staff, S1. LPA Valerio learned during this visit that S3 was assisting residents over the weekend. When S3 was questioned, S3 stated the residents are going to get S3 in trouble. Administrator Beatrice confirmed during this visit that paper work and training was still in the process for S3. S3 did not have any prior training or experience. Therefore, the allegation of Staff did not receive all required training is substantiated.

Staff do not provide appropriate supervision to residents in care.

On 10/24/2024, LPA Villanueva observed the facility to be in disrepair in Resident 1's (R1) room. On 11/05/2024, the facility was cited for the allegation f acility is in disrepair. On 11/05/2024, LPA Valerio observed R1's bedroom. LPA observed the holes next to the electrical socket to be repaired; however, the electrical socket was missing a cover. LPA observed the scratches on the window frame and bed frame still is disrepair. LPA Valerio interviewed staff regarding the R1's behaviors. According to the Administrator, R1 has had these behaviors but nothing has worked. They will fix the facility and R1 will go and do it again. LPA Valerio interviewed S1. S1 stated they try to give one hand activity to R1, but R1 will try to eat it. The amount of damage done, such as digging into the window seal and walls, show that the facility is not supervising R1 or attempting to redirect resident. During LPA's visits, S1 has been on shift without assistance to provide care and supervision to up to 6 residents while conducting daily activities.

The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was left at the facility.