Complaint Investigation Report

Based on records reviewed, it was revealed that 2 of 4 residents, resident1 (R1), and R3 were identified as requiring one on one (1:1) monitoring all or most of the time. It was further revealed that R2 requires 2-person assist with bathing and special observation at night due to confusion and forgetfulness. LPAs review of staffing schedule and interviews conducted revealed one staff member is on duty per shift consistently. LPAs observed 1 caregiver on duty during observations during both morning and afternoon shifts. Additionally, based on interviews, it was revealed that toileting and incontinence care for R2 is delayed due to one caregiver on duty per shift.

As a result, there is a preponderance of evidence to conclude that staff are not effectively meeting resident needs as identified through record reviews, interviews, and observations, therefore, this allegation is SUBSTANTIATED . Citations are issued under Title 22, division 6 as a result of this investigation and indicated on LIC 9099D. An exit interview was conducted with Maria Hinautan and a copy of this report was provided to Maria including LIC 811. Appeal rights provided.