Licensing Program Analyst (LPA) Alberto Lopez conducted a subsequent complaint visit to the facility and met with Daisy Hernandez, Executive Director and discussed the purpose of the visit, which was to reissue the licensing report.

During today’s visit, LPA took a tour of the facility, including random resident rooms, common areas of the facility, and interviewed eight (8) residents.

On 06/23/21, LPA Linda Almaraz conducted the initial visit. During the visit, LPA conducted Health and Safety check, requested staff/resident roster, and pertinent documents. On 09/29/21, LPA Almaraz conducted a subsequent visit. During visit, LPA conducted interviews with Staff #1-3, requested staff files and pertinent documents. On 10/22/21, LPA Almaraz and LPA Jewel Baptiste conducted a subsequent visit. During visit, LPA’s conducted Health and Safety check, interviewed former Administrator Jennifer Serrano, requested staff/resident roster, and pertinent documents.

According to Department interviews, and records reviewed, LPA interviewed 8 residents and 7 of 8 residents could not collaborated the allegation. Staff repeatedly instructed Care Managers, the last documented instance of which was 06/23/2020, to conduct more frequent status and incontinence checks for resident, since resident kept getting out of bed, or attempting to without calling for assistance to use the restroom. Hospice staff also advised the facility on 6/25/2020 to conduct more frequent checks. The facility does not document when room checks are done. The last documented time a staff member assisted resident with resident incontinence was on 06/25/2020, prior to being found on the floor at approximately 11:30PM, was at 08:06PM. This clearly shows that resident was not provided incontinence checks for nearly 3 and a half hours. Staff who were responsible for resident that night stated that staff usually did not conduct incontinence checks until 11:30PM-12:00AM. Staff told the Department that the facility concluded in its own investigation that staff failed to check on residents at the beginning of the overnight shift. Facility documents show that staff was counseled for failure to follow the instructions since staff “failed to conduct resident rounds at the beginning of the shift as is the procedure.” Based on staff interviews and documents reviewed, facility failed to provide adequate incontinence care to resident. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the 809D exit interview held, report, citation, and appeal rights provided, please see 809D