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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603504
Report Date: 02/23/2024
Date Signed: 02/23/2024 02:56:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2022 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220210150135
FACILITY NAME:LA POSADAFACILITY NUMBER:
198603504
ADMINISTRATOR:HILL, JANETTEFACILITY TYPE:
740
ADDRESS:8120 PAINTER AVETELEPHONE:
(562) 945-2651
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY:114CENSUS: 90DATE:
02/23/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Diana Bautista, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff are not following resident's care plan appropriately.
Staff does not provide proper meal service to residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on the above allegation. The purpose of the visit was discussed telephonically with Diana Bautista.


The investigation consisted of: On 2/15/2022, LPA toured all areas of the facility. Staff (S1-S7), residents (R1- R7), and Family (F1) were interviewed. Copies of Shower Lists [Hospice Shower Names, AM Shower list, PM Shower list], List of residents on 2-hour checks [17 residents], Assisted Living Dining Room Census, Staff Shift Schedule Dates- 1/3/2022- 2/13/2022 , LIC 500 Personnel Report and Resident Roster were obtained. During today's visit, no health and safety issues were observed.

***Narrative continues next page.***
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20220210150135
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LA POSADA
FACILITY NUMBER: 198603504
VISIT DATE: 02/23/2024
NARRATIVE
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Allegation: Staff are not following resident's care plan appropriately. It is alleged that the facility has been understaffed for several months and staff are falling behind on their work responsibilities i.e., shower assistance, distribution of medications in a timely manner, and checks on hospice and home health residents. Seven (7) residents were interviewed, of which four (4) stated that they are not being bathe as indicated in their care plans and admission agreements. Two (2) residents stated that they they had not been bathe in over 1 week, and they never know when they are going to be bathe because staff are not following their regular shower schedule. A total of seven (7) staff were interviewed. Four (4) out of seven staff confirmed that resident's care plans are not being followed as a result of staffing shortages. Staff reported that due to the staffing shortages staff are working 6 days a week, and they are still not meeting their needs. For example, a resident's wound was only being cleaned during day shift hours because there was insufficient staffing in the NOC shift, and other residents were not being provided incontinence care as required because when staff started their shift they were observing that the residents on the rotation log were not being changed because their clothes were soiled and wet. Staff stated that weekends and evenings are very challenging for staff because of staff shortages. It was reported that sometimes the NOC shift only had 1 staff in the Assisted Living floors, and 2 staff in the Memory Care unit, but at times 1 Memory Care staff has to be pulled to help the Assisted Living floors. Per document review, the findings indicate that facility caregiver staff have been working 12-hour shifts since at least November 2021, and has been using a total of 15 registry staff as a result of staffing shortages. Staff scheduling documents indicated that the Administrator and Wellness Director were scheduled to work as caregivers on at least 2 different dates. Per staff interviews, residents are to be showered a minimum of twice weekly.

Allegation: Staff does not provide proper meal service to residents in care. It is alleged that staff are delivering the meals late to residents, the food is cold, and residents that require feeding assistance are awaiting at least 40 minutes after food is delivered to receive assistance from staff. Based on document review, the findings indicate that there are 5 residents that require feeding assistance. Three (3) out of seven (7) residents stated that their food has been delivered late. Per staff interviews, meals were being provided to residents in their rooms as a result of a COVID-19 virus outbreak. On 2/14/2022, residents resumed dining services in the dining room. Administration staff stated that residents that require feeding assistance take approximately 30 minutes - 1 hour for meal consumption. Five (5) out of seven (7) staff stated that it is taking staff at least 30 minutes to go feed the residents that require assistance, because they are busy attending other resident needs. It was reported that on Sunday February 13, 2022, staff began passing breakfast meals at 9:15 am, and they finished at about 10:00 AM. The residents that needed assistance began eating their breakfast until past 10:00 AM, and on that day staff began serving lunch at an earlier time in order for lunch service to be on time.
Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited.
Exit interview was conducted and a copy of the report and appeal rights were issued.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 28-AS-20220210150135
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LA POSADA
FACILITY NUMBER: 198603504
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/01/2024
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Administrator agrees to conduct staff training on care plans and bathing schedules.

Submit a written POC and proof of staff training.
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Based on interviews and record review, between Nov. 2021- Feb. 2022, residents were not being showered at least 2 times per week due to staffing shortages related to the COVID-19 pandemic. This posed a potential health and safety risk to residents in care.
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Type B
03/01/2024
Section Cited
CCR
87464(f)(4)
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Basic Services. Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications..., as specified in Section 87608, Postural Supports.
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Administrator agreed to conduct staff training in Basic services and submit a contigency plan that addresses potential staff shortages and meal assistance.
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Based on record review and interviews conducted residents that required feeding assistance were being fed 30 minutes after food was serveda as a result of staff shortages between Nov. 2021 - Feb. 2022. This posed a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3