Inspection Reports for
Yorkshire Village

The complaint alleged neglect of a resident's hygiene needs, failure to meet dental needs including missing a scheduled oral surgery, and failure to conduct reassessments despite cognitive decline. The investigation found these allegations to be unfounded based on interviews, record reviews, and observations.

The investigation found that the allegations were unfounded. Staff made multiple attempts to assist the resident with hygiene despite refusals, dental treatments including oral surgery were provided as scheduled, and multiple reassessments and updated care plans were completed and documented.

The complaint alleged staff neglect leading to hospitalization and delayed medical attention for a resident. The investigation included interviews with staff, witnesses, and review of records. The complaint was found unsubstantiated, meaning there was insufficient evidence to prove the alleged violations occurred.

Based on interviews and record reviews, the allegations that staff neglect resulted in a resident being hospitalized and that staff did not seek timely medical attention are unsubstantiated. The investigation found that the resident received timely medical evaluations and was transported to the hospital as instructed by the Primary Care Provider.

The complaint alleged that multiple residents were covered in rashes and that staff were not addressing a scabies outbreak. The allegation was unsubstantiated after investigation, including interviews and document review.

The investigation found insufficient evidence to support the allegation of a scabies outbreak. Interviews with staff and review of medical and incident reports indicated no diagnosis or outbreak of scabies, and the facility followed proper protocols for infectious disease reporting.

The complaint alleged that staff mishandled a resident while outside the facility. The investigation included interviews with staff, residents, and review of documents including an incident report dated 9/29/23. The allegation was found to be unsubstantiated.

Interviews with residents and staff revealed no observed mistreatment or rough handling of residents. The resident in question became agitated during a medical appointment, and staff spoke louder to guide the resident without physical contact. The allegation was unsubstantiated due to lack of preponderance of evidence.

The complaint involved allegations that staff spoke inappropriately to residents and failed to answer call bells timely. The allegations were unsubstantiated after interviews, observations, and testing of call light systems.

The investigation found no preponderance of evidence to substantiate the allegations. Interviews with residents and staff indicated respectful communication and timely response to call bells. Observations and tests of call light systems confirmed staff responded within 2 minutes.

During the visit, no health or safety concerns were observed. The official death certificate had not been issued at the time of the visit, and the Executive Director was advised to submit it once available.

The complaint involved allegations that staff did not ensure nutritious meals for Resident 1 and failed to safeguard Resident 1's personal belongings, specifically three missing bracelets. The investigation was unsubstantiated due to lack of preponderance of evidence.

The investigation found that the facility generally provides balanced and nutritious meals according to their menu and accommodates special dietary needs, though some concerns about meal variety were noted. Regarding the missing bracelets allegation, evidence was inconclusive as some bracelets were found and returned, and the resident was no longer available for interview; therefore, the allegations were unsubstantiated.

The facility was found to be in compliance with all applicable regulations with no deficiencies cited. The physical plant, care and supervision, records, medications, disaster preparedness, and infection control measures were all satisfactory.

The complaint alleged staff did not safeguard a resident and failed to follow reporting requirements. The findings determined the allegations were unfounded due to the resident not being at the facility during the incident and no reporting issues were observed.

The investigation found the allegations to be unfounded as the resident was not residing at the facility at the time of the alleged incident. Interviews and record reviews confirmed no issues with safeguarding or reporting requirements.

The complaint alleged that staff mismanaged Resident #1's medication by administering 300 mg when the physician ordered 200 mg, and that staff restrained the resident by using a Geri chair and positioning the resident in bed to prevent exiting. Investigations included interviews with staff, administrator, hospice nurses, and review of medication orders and administration records. Resident #1 was on hospice and passed away on 2025-03-09. No conclusive evidence was found to substantiate the allegations.

Based on interviews, record reviews, and observations, the allegations that staff mismanaged the resident’s medication and restrained the resident in care may have happened or are valid, but there was not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations were determined unsubstantiated.

The Licensing Program Analyst delivered amended LIC9099 and LIC9099-C forms along with the report. No new deficiencies or findings are detailed in this report.

The analyst observed no immediate health and safety concerns and confirmed adequate staff coverage during the incident. Resident relocation was implemented for safety. No deficiencies were cited.

The complaint alleged staff physically abused residents and yelled at residents. The investigation found these allegations to be unfounded, meaning the allegations were false or without reasonable basis.

Based on interviews, records review, and discussions with facility staff, the allegations were found to be unfounded, with evidence indicating that the incidents involved resident-to-resident aggression rather than staff abuse.

The complaint investigation addressed allegations of staff verbally abusing a resident, staff physically abusing a resident, and staff failing to safeguard a resident's belongings. The verbal and physical abuse allegations were found to be unfounded. The allegation regarding safeguarding belongings was unsubstantiated due to lack of sufficient evidence.

The investigation found the allegations of staff verbally and physically abusing residents to be unfounded, with evidence indicating that the alleged aggressor was another resident. The allegation that staff did not safeguard a resident's belongings was unsubstantiated due to insufficient evidence, despite reports of missing items and possible theft by a former resident.

The facility was found to be operating within licensing conditions with no deficiencies cited. Physical plant, food service, staff training, medication management, and safety measures were all compliant with regulatory requirements.

The complaint involved allegations that staff administered medication without POA consent, did not meet the resident's hygiene needs, and failed to ensure use of the resident's walking device. The findings were unsubstantiated due to insufficient evidence.

The investigation found no preponderance of evidence to substantiate the allegations. Staff followed the resident's care plan and physician orders, hygiene needs were addressed with reminders and assistance despite resident refusal, and the walking device was available and used when possible. The allegations were deemed unsubstantiated.

The inspection was partially completed due to time constraints, with no deficiencies cited during this visit per Title 22, Division 6 of The California Code of Regulations.

The complaint alleged illegal eviction of Resident #1, who was accused of providing incorrect information and threatening other residents. The investigation found no basis for the allegation and deemed it unfounded.

The investigation included interviews and record reviews, concluding that the facility properly delivered a 30-day eviction notice with resources for alternate housing. The complaint was found to be unfounded.

Complaint 18-AS-20240105081727 was the reason for the visit; additional interviews were attempted but only the Executive Director was interviewed. No substantiation status was provided.

The Licensing Program Analyst conducted an interview with the Executive Director and documented the information. No additional interviews were conducted due to a staff witness calling out.

The allegation that residents were left in soiled diapers for an extended period was investigated and found to be unsubstantiated.

The investigation, including interviews and documentation review, found no evidence to support the allegation. The complaint was deemed unsubstantiated due to lack of corroborating evidence.

The facility was found to have implemented adequate infection control measures including symptom screenings, hand hygiene supplies, social distancing, masking policies, and sufficient PPE supply. No deficiencies were noted during the visit.

The complaint investigation was unsubstantiated, meaning there was insufficient evidence to prove the alleged violations did or did not occur.

The investigation found that the allegations were unsubstantiated. Record reviews and interviews confirmed that the resident was given medication as ordered and was able to leave the facility unassisted. There was no preponderance of evidence to prove the alleged violations occurred.

The complaint involved allegations that a resident was left on the floor for an extended period and that the resident fell and sustained an injury. Both allegations were unsubstantiated due to lack of preponderance of evidence.

The investigation found insufficient evidence to substantiate the allegations that a resident was left on the floor for an extended period or that the resident fell and sustained an injury. Both allegations were determined to be unsubstantiated based on interviews, document reviews, and observations.

The complaint alleged that staff were not allowing a resident to leave the facility. Interviews with residents and staff indicated residents were able to leave as they wished, and the allegation was unsubstantiated.

The investigation included interviews with residents and staff and a records review. The allegation was found to be unsubstantiated due to lack of evidence to prove the alleged violation.

The inspection found no health and safety concerns or deficiencies. The facility demonstrated appropriate infection control measures, sufficient PPE supplies, and staff training in PPE use.

The complaint alleged illegal eviction. The investigation was unsubstantiated, meaning there was not enough evidence to prove the alleged violation did or did not occur.

The investigation found that the facility provided an eviction notice to Resident #1 with a 30-day effective date and that the resident's belongings were retrieved before the eviction date. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.