Based on LPA Montoya’s records review, the victim, Resident #1, was admitted to the facility on 7/30/2019. According to the Physician’s Report dated 3/4/2021, Resident #1 has mild cognitive impairment but she is able to follow instructions, communicate her needs, and able to leave the facility unassisted.

During virtual tours for health and safety checks on 3/11/2021, LPA observed residents are well, the home is clean and in order, there are sufficient perishable and non-perishable food supplies, PPE and hygiene supplies were readily available for staff, and the facility has two caregivers providing care to six residents. LPA observed the window by the kitchen that staff stated had no screen for many years has now been covered with a new screen. During the virtual visit on 3/12/2021, LPA checked all exit doors for auditory signal devices. LPA observed the main door and one of two sliding doors have working auditory devices but the sliding door by the kitchen has no auditory device or other staff alert feature to monitor this exit door for residents with memory care needs. LPA checked other parts of the homes such as the bathrooms, kitchen, living room, dining room, and backyard and observed no other things that present a hazard to residents.

On 3/17/2021, LPA conducted a subsequent virtual tour with Staff #2 and observed a centralized heater, air conditioner in living room and dining room. In addition, LPA observed a wall air condition in Residents’ #3 - #6 bedrooms, a portable air condition in Resident #1’s bedroom, an electric fan in Resident #2’s bedroom and four more extra electric fans in the living room. LPA checked and observed the air conditioners, electric fans and the centralized heater are all in working conditions.

Allegations: Facility has infestation of flies.

It is alleged that the facility has an infestation of flies. Based on the interview, Staff #1, #2, #3, # 4 and #5 stated they observed a few flies enter the facility through the exit doors or through the kitchen window that had no screen. They all stated that on-duty staff would swat the flies away at once upon their entry. During an interview on 3/11/2021, Staff #3 informed LPA Montoya that a new screen on the kitchen window was recently installed.

Resident’s room temperature is not kept within acceptable range.

It is alleged that the resident’s room temperature is not kept within an acceptable range. Interview with Staff #1-#6 revealed Resident’s room temperature is kept within an acceptable range. Staff #2 stated that there are wall air conditioners in resident bedrooms, living room, and dining room as well as available electric fans for resident use including a centralized heater and portable heaters. Staff #2 mentioned that during summer, the temperature in common areas is maintained around 69-74 degrees Fahrenheit and 75-76 degrees Fahrenheit during winter or as desired by residents. Staff #2 also mentioned that the temperature in each resident bedroom is adjusted according to each resident’s preference. Staff #5 and #6 stated on-duty staff ensures that residents are comfortable, and staff would adjust the heater or air conditioner according to the resident's preferred room temperature. Interview with Residents #1, #3, #4, #5, and #6 revealed resident’s room temperature is always within an acceptable range and they are comfortable. Resident #2 was unable to provide statements due to his medical condition.

During LPA’s virtual tour on 3/17/2021, LPA observed a centralized heater, air conditioner in the living room and dining room. Also, LPA observed a wall air condition in Residents’ #3 - #6 bedrooms, a portable air conditioner in Resident #1’s bedroom, an electric fan in Resident #2’s bedroom, and four more extra electric fans in the living room. LPA checked and observed the air conditioners, electric fans and the centralized heater are all in working conditions. Based on the Department’s observations and interviews, the department did not find sufficient evidence to corroborate this allegation.

Staff locked resident in her bedroom.

It is alleged that staff locked resident in her bedroom. Based on interview, Staff #1, #2, #3, #5, and #6 denied staff locked resident in her bedroom. Staff #4 stated in an interview he did not know whether or not staff locked a resident in her bedroom. Staff #2 and #3 stated Resident #1 placed a door stopper on her bedroom door to avoid Resident #2 who likes to wander into other resident bedrooms. Interview with Residents #1, #3, #4, #5, and #6 denied that any resident was locked by staff in his or her bedroom. Interview with Resident #1,

REPORT CONTINUED IN LIC 9099C

Facility is not providing food of the quality and quantity to meet resident's needs.

It is alleged that facility is not providing food of the quality and quantity to meet resident's needs. Based on LPA’s interview, Residents #1, #4, #5, and #6 denied the facility is not providing food of the quality and quantity to meet resident’s needs. Resident #1 stated the facility always serves good food, snacks are available and always accessible to residents. Resident #3 stated in an interview that the quality and quantity of food were acceptable, however, she would want the facility to provide more variety of fresh fruits. During the interview, Residents #5 commented that the facility serves delicious food. Resident #6 stated that facility serves good food. Interview with Resident #1, #3, #4, #5, and #6 revealed staff serves snacks to residents in between meals. Staff #1, #3, #4, #5, and #6 revealed in interviews that no resident nor resident’s family member complained about the quality and quantity of food that the facility serves. However, an interview with Staff #2 indicates a family member of Resident #1 was not satisfied with the quality of food the facility serves. Staff #2 stated he informed Staff #6 about this concern and it has been resolved. Staff #6 denied when questioned by LPA that there was an issue about the quality of food the facility serves. During LPA’s virtual tour of the facility on 3/11/2021, LPA did not observe the cooked food that was served on that day, however, LPA observed that the facility had sufficient perishable and non-perishable food supplies. LPA’s review of facility’s monthly food menu shows a variety of food selections including snack options. Based on LPA’s observations during interviews with Staff #3 and #5 who are responsible in cooking meals revealed that they don’t necessarily follow the menu, but they serve similar types of food. Resident #2 was unable to provide statements due to his medical condition. Based on obtained information, the Department did not find sufficient evidence to support the allegation mentioned above.

Due to neglect/lack of supervision, resident wandered.

It is alleged that due to neglect or lack of supervision, a resident wandered. During an interview, Resident #1 denied that she wandered. Resident #1 stated she does not go out of the facility unassisted.

REPORT CONTINUED IN LIC 9099C

During the interview, Staff #1 and #6 stated there was no police report on the allegation that a resident wandered. Staff #6 stated a police report was not necessary because resident was not missing, she was supervised by a staff while she was out. Interviews with Staff #2 - #5 indicate they don’t know whether or not there was a police report on Resident #1’s alleged wandering incident. Based on the Department’s interviews, the department did not find sufficient evidence to corroborate this allegation.

Based on information gathered, the Department did not find sufficient evidence to support the allegations, “Facility has infestation of flies”, “Resident’s room temperature is not kept within acceptable range”, “Staff locked resident in her room”, “Facility is not providing food of the quality and quantity to meet resident's needs”, and “Due to neglect/lack of supervision, resident wandered”.