Complaint Investigation Report

Interviews revealed that R1 shared a room with Resident 2 (R2) who employed private caregivers who provided R2 with companionship and were present in the shared room for about 20 hours a day. Interviews with facility staff revealed that staff are tasked with checking on residents who require assistance with incontinence care every 2 hours. Interviews revealed that facility staff were aware that R2’s private caregivers were not responsible for providing any care for R1 or providing any housekeeping or cleaning of the shared room. Interviews revealed that facility staff did not conduct safety checks on R1 resulting in R1 sitting in soiled incontinence briefs. Interviews revealed that on at least one occasion, R1 had soiled an incontinence brief resulting in a urine odor which originated from a fabric chair. Interviews revealed that on at least one occasion, there was feces on the floor of R1’s room and it was not cleaned for several hours and after multiple requests for staff to clean the room. Interviews revealed that R2’s private caregivers would change dirty sheets, clean the shared room, and provide incontinence care for R1.

The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has been met, therefore, these allegations are deemed substantiated. The following deficiencies are cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page.

An exit interview was conducted with Memory Care Director Aileen Spence, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).