Complaint Investigation Report
Shower logs from 11/1/2024 to 2/13/2025 documented R1 was only given 9 full showers, 4 logs indicating only feet or hair being washed, and 5 refusals in 3.5 months which amounts to less than then 1 bath per week and is less than the 2 baths per week indicated in R1’s admissions agreement. During investigation, LPA conducted interviews with residents’ and staff. On 12/6/2024 CCL conducted complaint 21-AS-20240930151325 investigation and found same allegations Substantiated. Based on interviews conducted, observations made, and record review, the allegation listed above is SUBSTANTIATED .
Due to previous citation of regulation 87464(f) (4) given on 12/6/2024 a $250 civil penalty will be assessed for repeat violation in less than 12 months.
Staff do not respond to call button requests in a timely manner- Complainant alleges when R1 presses their call button, and it takes a long time for a response. LPA conducted interviews with residents and staff. Interviews with Administrator and RSD indicated staff should respond to a residents call within 15 minutes. And although the call bell system has been updated with a few pendants replaced we have not decreased the response times as we would have liked. We have hired 5 new staff although 2, due to scheduling conflicts have left. Documents obtained confirmed that over a 1-month period (1/5/25 -2/20/25), R1 waited 15 minutes or more 94 times before receiving staff assistance, 14 of which were for wait times greater than 30 minutes, and 4 were for wait times greater than 60 minutes. On 12/6/2024 CCL conducted complaint 21-AS-20240930151325 investigation and found same allegation 87411 (a) Substantiated. Based on interviews conducted and record review, the allegation listed above is Substantiated .
Due to previous citation of regulation 87411(a) given on 12/6/2024 a $250 civil penalty will be assessed for repeat violation in less than 12 months.
Staff do not ensure residents room is kept free of mal odors- Complainant alleges staff will not tend to R1’s catheter care needs in a timely manner which causes the residents room to smell bad. LPA conducted facility visits on 2/20/2025 (with LPA Ethel Contreras) & 5/1/2025 on both days observing a strong mal odor in R1’s room, on second visit Administrator observed odor out into the hallway.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction