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32 | CONTINUED...During the course of the investigation, 4 of 4 interviewees indicated there were 2 staff working in Assisted living area and two staff working in the memory care unit during incident of R1s wandering behavior. Three of four interviewees indicated the need for additional staffing during the night shift.
Regarding the allegation that “Staff did not adequately notify resident’s authorized representative of a change in resident's placement,” the investigation revealed the following: The Facility attempted to communicate with who the facility staff believed to be R1’s responsible party; however the facility contacted a Family member identified on the LIC 601-Identification and Emergency Form under Person(s) responsible for financial affairs, payment for care, legal guardian if any, but not the authorized representative.
Regarding the allegation that “Staff inappropriately placed resident in a locked unit,” the investigation revealed the following: The facility did not provide the resident and responsible party with a 30 day notice, and did not communicate with Authorized representative prior to placing the resident in delayed egress memory care unit. Although, the facility was attempting to ensure R1s Health and Safety by placing R1 in delayed egress memory care unit, the facility attempted to substitute R1’s supervision needed to meet R1s need and provide necessary supervision.
Therefore, based on evidence through records reviewed and interviews conducted the allegations “Staff did not provide adequate supervision, resulting in a resident wandering away from the facility,” “Staff did not adequately notify resident’s authorized representative of a change in resident's placement,” and “Staff inappropriately placed resident in a locked unit” are determined to be SUBSTANTIATED, meaning the complaint allegations are valid and that a violation has occurred. (SEE LIC 9099-D)
The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.
An exit interview was conducted with (AD) Jeri Miles and (HWD) Brisseth Rivera, and a copy of this report, Appeal rights, LIC 9099-D page, and LIC 811- Confidential names were provided at exit. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Deficiency Dismissed
Type B
06/26/2024
Section Cited
CCR
80072(a)(2)(3) | 1
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7 | 80072:Personal Rights(a)each client shall have personal rights which include...
(2) To be accorded safe, healthful and comfortable accommodations,...to meet his/her needs.(3)To be free from corporal or unusual punishment, infliction of pain, humiliation, CONTINUED... | 1
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7 | AD Jeri Miles and HWD Brisseth Rivera agreed to read and understand CCR 80072, provide inservice to facility staff and submit proof of understanding to CCLD by 6/25/2024. |
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14 | CONTintimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature...This requirement was not met as evidenced by: The facility did not provide the resident and responsible party with a 30 day notice, and did not communicate with Authorized representative prior CONT... | 8
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14 | to placing the resident in memory care. Although, the facility was attempting to ensure R1s Health and Safety by placing R1 in memory care unit, the facility attempted to substitute R1’s supervision needed to meet R1s need and provide necessary supervision. This poses a potential risk to residents in care. |
Deficiency Dismissed
Type B
06/24/2024
Section Cited
CCR
87464(f)(1) | 1
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7 | 87464(f)(1):Basic Services shall at a minimum include: (1) Care and Supervision as defined in Section 87101(c)(3) and Health & Safety Code 1569.2(C) "care and supervision means the facility responsibility for or provides or promises in future, ongoing assistance with activities CONT... | 1
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7 | AD Miles agreed to provide in-service training to facility staff regarding care and supervision and submit proof of udnerstading of CCR 87464 by POC due date of 6/25/2024. In addition, HWD Rivera indicated desire to enroll in AD certificate course to learn Title 22. |
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14 | assistance with activities of daily living without which the resident's physical, mental, health & safety, or welfare would be endangered. This requirement is not met as evidenced by the complaint investigation:The facility did not provide the resident and responsible party with a 30 day notice, CONT | 8
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14 | and did not communicate with Authorized representative prior to placing the resident in delayed egress memory care unit. Although, the facility was attempting to ensure R1s Health and Safety by placing R1 in delayed egress memory care unit, the facility attempted to substitute R1’s supervision needed to meet R1s need and provide necessary supervision.This poses a potential risk to the residents in care.
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