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13 | Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint investigation visit and delivered findings.The purpose of the visit was explained to Marina Galaviz.
The investigation consisted of the following: On 4/29/2021 due to the COVID-19 pandemic a telephonic visit was conducted. LPA was not able to conduct a virtual physical plant inspection on that date because there was no Administration staff available to assist. Administrator/staff (S1) was interviewed via phone on 5/5/2021. On 5/12/21, resident (R1) and staff (S2) were interviewed and R1's room was observed during site visit. Random resident rooms were inspected. Resident (R1) file documents were obtained [ Identification and Emergency Information, Physician Report, Appraisal, Assisted Living Waiver ISP Plan, Resident Personal Property and Valuables list, "Medication Verification Form", Physician Order, LIC 613-C-2, Admission Agreement, resident roster, Medication Administratiom Records, and staff contact information/LIC 500 Personnel Report. During today's visit, staff (S3-5) and residents (R2-R5) were interviewed.
See LIC 9099C |
| Substantiated | Estimated Days of Completion: |
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32 | Allegation: "Staff is not communicating with residents appropriately." Based on interviews conducted and records review the findings indicate there are at least 10-12 residents of Asian descent that do not speak or understand English. At least 30-40 % of the resident population is Asian and does not speak English. Only one (1) staff that works part-time speaks Cantonese/Mandarin assists with translation. In addition, all the documents provided to residents and their responsible parties are in English. Required postings such as complaint information, non-discrimination notice, and Personal Rights are not posted in any other language other than English. Staff interviews revealed that staff use body language and/or call the Asian descent residents' families when there are issues, or when the resident's have a complain.
Allegation: "Licensee did not make resident’s records available to the responsible party." Based on interviews conducted and record review resident (R1) moved in on Saturday April 3, 2021. The resident's responsible party signed Admission documents on April 1, 2021. However, copies of the Admission Agreement and the Assisted Living Waiver Contract were not provided to R1's responsible party upon admission. Responsible party contacted Administrator and was suppose to pick up documents on April 19, 2021, but they were not furnished because Administrator forgot to leave the copies for pick-up. Administration staff confirmed that R1's responsible party did not receive admission document copies as required per Title 22.
Based on observation, record review, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22. See LIC 9099D.
An exit interview was conducted and Plans of Correction were reviewed and developed with Resident Care Coordinator. A copy of the report and appeal rights were discussed and left with Marina Galaviz.
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
07/08/2021
Section Cited
CCR
87468(d) | 1
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7 | 87468(d). Personal Rights. Licensees shall post the personal rights, nondiscrimination notice, and complaint information specified above in English, and, in any other language in which at least five (5) percent of the residents can only read that other language.
This requirement was not met by evidence of:
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7 | Staff agreed to submit a written plan of correction along with proof that the required postings have been posted in any other language in which at least 5% of the population reads.
Submit POC by due date. |
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14 | Based observation and interviews conducted the facility has failed to post required documents i.e. Personal Rights, complaint information, and non-discrimination notice in any other language such as Mandarin. Approximately 30 -40 % of the resident population is of Asian descent and does not speak English. This poses a potential health and safety risk. | 8
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Type B
07/08/2021
Section Cited
CCR
87507 | 1
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7 | 87507(e). The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. The licensee shall provide additional copies to the resident or resident’s representative upon request.
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7 | Staff agreed to submit a written plan of correction stating how this deficiency was corrected. Include a copy of the documents.
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14 | Based on record review and interviews conducted the facility failed to provide R1's responsible party a copy of the admission agreement upon signing it on April 1, 2021. Resident (R1) moved in on April 3, 2021. As of April 19, 2021, responsible party had not received the copies. | 8
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