Complaint Investigation Report

On 05/01/2024, LPA interviewed four (4) residents and one (1) staff. Four out of four resident interviewed agreed that it is challenging communicating with staff #1 since he cannot hear. Administrator acknowledged understanding and reported that moving forward she will ensure that staff #1 is on duty with another staff.

Regarding allegation - Staff is not providing adequate care and supervision - It was reported that since staff #1 is unable to communicate effectively with the residents in care and the only staff on duty at the time, adequate care and supervision is not provided to the residents. Four out four residents interviewed including a credible witness revealed that when staff #1 is the only staff on duty adequate care and supervision is not afford to the residents especially in case of an emergency. Based on interviews, allegation “Staff is not providing adequate care and supervision” is deemed Substantiated at this time.

Regarding allegation - Staff did not afford a resident privacy - It was reported that staff were observed assisting resident with under garments in the room with the door open. Staff reported they usually do close the door when assisting residents with hygiene/toileting. Residents interviewed expressed that they really haven't paid attention if their room door is closed or left open when staff assist them with anything. Credible witness provided information that they witnessed staff assisting resident in the room with hygiene /toileting needs. Staff did not afford resident privacy by changing resident with the door open. Based on interviews, allegation “Staff did not afford a resident privacy” is deemed Substantiated at this time.

Regarding allegation - Staff are not properly trained - It was reported that the staff are not properly trained of residents care and personal rights. To investigate this allegation staff was interviewed and training records were reviewed on 5/15/2024. Training records for staff #1 were incomplete with missing training times (duration). Also interview conducted with staff #1 revealed that additional training is required for staff #1. Staff was unable to respond to questions asked by LPA regarding residents personal rights, and residents plan of care. Based on interviews, records review and observation, allegation “Staff are not properly trained” is deemed Substantiated at this time.

Regarding allegation - Staff do not properly maintain a resident's room - It was reported that there are two buckets in resident's room beside the bed. During the physical plant tour LPA observed these buckets in resident #1's room (with no lid) beside residents bed. Resident interviewed did provide any information. Staff were informed to remove the buckets from the residents room and provide a trash basket with a lid. Based on observation, allegation “Staff do not properly maintain a resident's room” is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency will be cited (refer to LIC 9099-D) Exit interview conducted, appeal rights discussed, and a copy of the report provided.