Allegation: Facility staff do not ensure that facility is free of pest.

The investigation into the allegation that facility staff do not ensure that facility is free of pest consisted of interviews and record reviews. Based on a review of various records and interviews conducted with staff, there are mixed findings regarding the effectiveness of pest control measures at the facility. According to the contract with Clark Pest Control, the technician is required to inspect both the interior and exterior of the facility twice monthly, addressing any pest activity and providing inspection reports after each service. The service scope includes addressing insect issues such as roaches and bed bugs, as well as preventive measures for rodents. Extra services are also available upon request.

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The reviewed records from Clark Pest Control's service reports between 6/24/2024 and 12/26/2024, confirm that the facility has received pest control services at least twice a month. During these visits, technicians addressed primarily insect issues and took preventive measures for rodents. For example, on 12/26/2024, the technician inspected both the interior and exterior of the facility, replaced non-toxic monitors, and reported minimal insect activity. The technician also treated the kitchen and baited the hallway to control cockroaches. However, it was noted that a service attempt in room #120, occupied by Resident_1 (R1), was refused by the R1, who did not want chemicals used in the room. This refusal was recorded in both the service report and the pest sighting log, which also noted a cockroach sighting in R1’s room on 12/26/2024.

The Pest Sighting Log from 8/17/2023 to 12/26/2024, tracks sightings of pests reported by staff and/or residents. The log shows that sightings of cockroaches in R1’s room were logged, with the technician addressing these sightings on 12/26/2024, despite R1’s refusal of service. According to the log, no further actions were taken to address the pests in R1’s room after the refusal.

An interview with Staff_1 (S1) revealed that S1 accompanied the Clark Pest Control technician to R1’s room on 12/26/2024. S1 confirmed that R1 refused the service, citing concerns about chemicals in the room. S1 further stated that no additional attempts had been made to address the cockroach issue in R1’s room following the refusal.

The records and interviews suggest that the facility is generally proactive in addressing pest control, with services provided regularly by Clark Pest Control. It is unclear whether further steps are being taken to respect the resident's preferences while also ensuring the facility remains pest-free. This could potentially impact the overall effectiveness of pest control measures at the facility. Based on the information gathered, this allegation was UNSUBSTANTIATED.

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Allegation: Illegal Eviction.

The investigation into this allegation consisted of interviews and record reviews. On 1/29/2025, LPA conducted interviews regarding an alleged illegal eviction of (R1) from the current facility.

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According to Witness_1 (W1), R1 was served an eviction notice by the facility on 1/17/2025, which gave R1 until 2/16/2025, to vacate the premises. W1 expressed concerns about the difficulty of finding an alternative placement for R1, as this facility was the only one willing to admit R1. W1 added that R1 was willing to move to either Sacramento or Contra Costa County and that R1 was actively trying to help find another placement. However, W1 acknowledged that R1 could be "colorful" in R1’s communication, making the process more complicated. W1 further noted that R1 had financial difficulties from the start, which contributed to the eviction, as R1 had not paid rent since R1’s admission in October 2024. Despite attempts by W1 to reach R1's social worker, no response was received.

In a separate interview, R1 confirmed that R1 received the eviction notice hand-delivered by facility staff Sherry Richardson and Susan McClure. R1 disclosed that R1 had attempted to make payments on 12/27/2024, and 1/6/2025, but was informed that the business manager, following instructions from the administrator, would not accept the payments. R1 was unsure why payments were denied and could not provide evidence of the checks R1 attempted to submit. Interview with business manager confirmed that the refusal to accept payment was due to a verbal notice of eviction from the meeting held in December 2024.

Susan McClure, the Assistant Administrator, provided additional context regarding the eviction during an interview on 12/31/2024. She explained that the eviction was being pursued due to R1's failure to pay rent and R1’s problematic behaviors, including refusing care, medication, and food. McClure noted an incident where R1 allegedly attempted to strike staff with a grabber, though no injuries occurred. Furthermore, Susan indicated that R1 had made inappropriate accusations towards male staff members when they entered R1’s room.

A record review of the eviction notice revealed that it was based on R1's arrears of $6,080.28, with no rent payments made since R1’s admission. The notice was hand-delivered to R1 by Richardson and McClure and also emailed to W1. The eviction notice was accompanied by an invoice detailing the outstanding rent amount.

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Based on the gathered information, the facility's actions appear to be within the bounds of the eviction process, as they followed protocol for notifying both R1 and R1’s social worker. Based on the gathered information, this allegation was UNSUBSTANTIATED.

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Allegation: Facility staff do not provide meal to meet residents' dietary needs.

The investigation into this allegation consisted of interviews and record reviews. On 12/31/2024, an interview was conducted with Assistant Administrator Susan regarding the allegation that facility staff do not provide meals to meet residents' dietary needs. Susan explained that staff are aware of residents' dietary restrictions and preferences, maintaining a list to ensure proper food delivery. She emphasized that they always follow these dietary guidelines and that they have a binder that staff use for reference and training. Susan also noted that some residents, like R1, may refuse the food provided, but this does not indicate a failure to meet their dietary needs.

On 1/29/2025, LPA Arvin Villanueva conducted an interview with R1 concerning food service. R1 confirmed that food trays are brought to her daily. According to a review of R1’s food preferences on file, R1 primarily eats vegetables, refrains from eating most meats, but consumes chicken, turkey, and eggs. Additionally, R1 enjoys drinking wine. There is no indication in the records that R1 requires a special diet.

Further review of R1’s care notes revealed that R1 often refuses the food tray delivered to R1’s room and does not eat in the dining room. These notes, however, did not suggest any failure on the part of staff in meeting R1’s dietary needs, as no special diet was prescribed. Additionally, R1’s care plan, dated 9/20/2024, and ALWP assessment, dated 6/4/2024, both confirmed that R1 does not require any special dietary accommodations. Based on this information, there is no preponderance of evidence to suggest that the facility staff do not meet R1’s dietary needs, therefore, this allegation is UNSUBSTANTIATED.

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The investigation into this allegation consisted of interviews, observation, and record reviews. The assistant administrator, Susan, in an interview conducted on 12/31/2024, indicated that staff generally respond to calls in a timely manner. However, she explained that R1’s selective preferences for certain staff, who are not always on schedule, may contribute to delays in care. Susan noted that R1 only allows a few specific staff members to assist R1, which can affect response times when those staff members are unavailable. Additionally, at times, R1 would not let staff turn off R1’s pendant until they are finished helping R1.

Further interviews with staff members provided additional context. Staff member (S2) indicated that R1 has been difficult, citing instances where R1 screamed at staff or accused them of stealing R1’s mail. S2 suggested that R1 tends to call during busy periods, when care staff are attending to other residents, and that R1 doesn't always call when staff have time available. In contrast, S3 highlighted that, while the assigned caregiver may be busy, other staff members usually respond to R1’s call. S3 mentioned that R1 often leaves R1’s pendant on until staff completes the task with R!, and noted that the ideal response time for calls is within 10 minutes, although this may vary if staff are busy with other residents. S4 described the process of responding to pendant calls, where staff are expected to arrive within 2-3 minutes. However, S4 mentioned that R1 often does not turn off R1’s pendant until the staff has fully completed the task R1 requested, which could contribute to longer pendant light durations.

Record reviews from R1's care notes also reveal a pattern of complaints regarding unresponsiveness to calls. For example, on 10/13/2024, R1 complained of not being helped when pressing the call light, although caregivers stated they had responded. On 10/25/2024, R1 accused the front desk staff of ignoring her calls, which was explained by the fact that the front desk staff were busy with other duties. Similarly, on 12/3/2024, R1 expressed frustration when a preferred caregiver was unavailable, and only caregivers R1 did not like responded. R1 has also been noted to scream when there is a delay in response time, even if it is only 2-3 minutes.

A review of the call light/pendant response data further illustrates significant variability in response times, ranging from as little as 6 seconds to as long as 1 hour and 27 minutes. Staff interviews corroborated that R1’s refusal to turn off the pendant light until staff have finished their tasks with R1 may account for this wide range in response time.

On January 29, 2025, during a complaint follow-up visit, the LPA conducted a test to measure the response time to R1's pendant call. Using a timer, the LPA noted that it took 19 minutes and 23 seconds for staff to respond to R1’s call, which was recorded after R1 pressed the pendant button. Staff member explained that she had just arrived at work when responding to the call.