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32 | During the visit, LPA toured the facility, conducted interviews with staff and clients, and obtained documents pertinent to the investigation.
On the allegation: Staff inappropriately handled resident. On 11/17/2021, Resident #1 (R1) called the San Luis Obispo (SLO) Crisis team as R1 had become angry at one of the staff members at the facility. SLO Crisis Team came to the facility due to R1 was experiencing suicidal ideation while on the phone. Facility staff continued to ask R1 if they could help. R1 called S1 a derogatory name, S1 then called R1 a derogatory name. R1 then went into R1’s bedroom and punched a night stand with their hand. Staff #2 (S2) gave R1 and ice pack. The crisis team tried coming up with a safety plan for R1 and for the staff to care for R1. The crisis team told the staff that R1 was having suicidal ideations and had a plan to carry it out. S1 stated “how is R1 cutting their wrist suicidal?” The crisis team explained that R1 had a long history of suicide attempts and had marks on wrists from previous attempts. The crisis team then decided to transport R1 to Marian Medical Hospital. R1 was later released the same night back to the facility. Per the Administrator, S1 completed the suicide ideation training 11/23/2021. Based on the information obtained, the allegation staff inappropriately handled resident is substantiated at this time.
On the allegation: Staff spoke inappropriately to resident. On 12/17/2021, at 10:57am, LPA Luong attempted to contact S1 for an interview. The LPA left a voice mail but did not receive a return call. The LPA conducted interviews with Staff #2 (S2) and Staff #3 (S3) who both confirmed that they have witnessed and heard S1 speak to R1 using derogatory language calling R1 a “bitch”. Crisis Team member also confirmed they witnessed S1 calling R1 a “bitch.” Based on information obtained through interviews, the allegation staff spoke inappropriately to resident is deemed substantiated at this time.
Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D).
Exit interview conducted, appeal rights discussed, and a copy of this report issued. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
08/12/2022
Section Cited
CCR
85165(b) | 1
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7 | 85165 Emergency Intervention Staff Training (b) Staff who use, participate in, approve or provide visual checks of manual restraint or seclusion, shall have a minimum of sixteen hours of emergency intervention training and be certified for having successfully completed thetraining. This requirement | 1
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7 | Facility will submit proof of emergency intervention staff training. Submit to CCL by 08/12/2022 to LPA Jeffries by email. |
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14 | is not met as evidenced by:Based on record review and interviews, the licensee did not comply with the section cited above. Licensee failed to ensure that staff had proper knowledge and training in crisis intervention as S1 was unaware of R1’s suicidal ideations, which posed a | 8
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14 | potential health and safety risk to clients in care.
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Type B
08/12/2022
Section Cited
CCR
80072(a)(1) | 1
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7 | 80072(a)(1) Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff | 1
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7 | Facility will submit proof of staff training in client personal rights. Submit to CCL by 08/12/2022 to LPA Jeffries by email. |
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14 | and other persons. This requirement is not met as evidenced by:Based on interviews, the licensee did not comply with the section cited above. Licensee failed to ensure R1’s personal rights as S1 used derogatory language towards R1, which posed a potential health and | 8
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14 | safety risk to clients in care.
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