Complaint Investigation Report

Hazardous material concerns were noted after approximately ten cans of paint were found stored in the same room as the residents’ refrigerator. Medication administration and documentation also showed extensive deficiencies, including missing MAR signatures, undocumented dosage changes, handwritten alterations, lack of destruction records, incomplete prescription information, missing PRN documentation, and improperly filed medication records. . Bathroom access and privacy concerns were also documented. Although the home houses six residents and three staff, it has only two bathrooms, with one was remodeled to include wheelchair access.

The resident bathroom was overcrowded with two shower chairs stored inside the shower area, and its lock could be easily disengaged from the outside. Bedroom conditions were substandard, with overcrowded storage, belongings stacked or bagged along walls, a hole in the door of Bedroom #1, and one resident’s mattress placed directly on the floor without proper documentation or approval. Additional health and safety concerns were observed in the backyard, including a mop bucket filled with dirty water, a large, gated garden area restricted to staff-only use, and a padlocked shed containing residents’ personal property to which residents had no access. Finally, fire safety issues were identified when smoke detectors in Bedroom #1 and the hallway were found chirping, indicating low batteries or malfunction, and staff were unable to identify the company responsible for installation or maintenance.

Based on LPA's observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations is being cited on the attached LIC 9099D

Appeal rights provided. a copy of the report was read and given to staff, exit interview conducted.