Complaint Investigation Report

LPA reviewed facility schedule from April 2023- July 2023 and observed one staff on shift for PM on 7/20/23, one staff on NOC on 7/21/23 and on staff AM for 7/22/23 and 7/23/23. Regulation 81065.5 states “there shall be at least one direct care staff person on duty, on the premises, any time clients are in the facility.” And “another direct care staff personal shall be on call and capable of responding within 30 minutes.” Administrator stated there are always Management available to respond to issues at a nearby facility in less then 30 minutes. Based on the information obtained, the allegation is deemed Unsubstantiated at this time .

On the allegation: Staff are not keeping accurate resident records. It was alleged that clients medical documents are mixed with other clients medical documents. LPA interviewed staff who stated this used to be a problem a long time ago until they got a records person and it is not a problem. LPA reviewed resident documents and observed them to be organized and in individual folders. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

On the allegation: Facility is not adequately assisting with medications. It was alleged that staff are not properly trained on how to pass medications and are only told to “watch a Relias Trainer video” but do not provide hands on the job training. LPA reviewed staff training and observed staff take a course called Medication Management for Unlicensed staff (med aides) which is a 60 minute course then shadow the nurse for around 2 hours prior to assisting with medications. LPA reviewed 4 clients medications on 10/03/2023 and observed medication to be properly documented and accounted for. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

On the allegation: Staff violate clients personal rights. It was alleged that staff racially profile African American clients, call the police and are much harsher with them versus Hispanic or white clients. It is also alleged that staff do not use the proper pronouns that clients want them to use. LPA interviewed Staff and Clients. Clients stated their rights were not violated and one client had been roommates with someone who asked to be called a (he/him) and the roommate said there were never any issues that they saw and staff tried to call the client by their preferred pronoun. Staff interviewed stated that Staff sometimes make pronoun mistakes but try their best to get it correct, it’s not deliberate. Staff also stated racially profiling happened earlier in the year but the person hasn’t been working since. This complaint allegation was already investigated on the 4/20/2023 complaint and the facility was cited for the violation of personal rights. The investigation for the current complaint did not reveal any evidence that staff acted inappropriately after the other complaint time period. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of the report issued.