Complaint Investigation Report

The allegation of reporting requirement non-compliance is SUBSTANTIATED based on LPA Jensen's determination that the Community Care Licensing Department did not receive a timely written report of outage which qualifies as an incident that threatens the welfare, safety or health of any resident . A finding of substantiated means the preponderance of evidence standard has been met.

LPA Jensen also reviewed the LIC 610E. The facility's approved Emergency Disaster Plan was last updated 1/4/23 and has been reviewed by 7 staff members including the Executive Director, Dietary Director, Resident Care Director, Resident Care Coordinator and Administrative staff. Under the LIC 610E Sheltering Place subsection specific to self reliance for periods of not less than 72 hours immediately following any emergency or disaster, including but not limited to , a short term or long term power failure it stipulates that in the event of a long term power outage "families will be notified to see if they want to bring the resident home, if needed we would relocate to sister community (Orangeburg). During the course of the first power outage, approximately 25% if the resident families were not contacted to be given the option of bringing the resident home. In addition, the LIC 610E indicates a plan to "contract with outside company to provide us with generator if power to be off for a few days. The Executive Director advised that while an outside vendor was contacted for potentially supplying a back up generator there was no 3rd party vendors available at the time due to such a large region being affected by outages. The Executive Director also advised that the facility's electrical panel is not adequately equipped for back up generator purposes however the faciloty is currently in the process of upgrading the electrical system. Based on LPA Jensen's review of the LIC 610E and interviews conducted the allegation of Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency were not properly implemented by facility staff is SUBSTANTIATED. A finding of substantiated means the preponderance of evidence standard has been met.

Deficiencies are being cited from the California Code of Regulations (CCR) and Health and Safety Code (HSC). Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were given.