Inspection Reports for Pasadena Nursing Center

The visit was an unannounced Proof of Correction (POC) inspection to verify compliance with a previously cited deficiency related to personal rights under Section 87468.1(a)(2).

The facility was still not in compliance with the cited Type B deficiency regarding personal rights as of the inspection date. An exit interview was conducted and a copy of the report was provided to the administrator.

The inspection was an unannounced complaint investigation triggered by an allegation that staff unlawfully evicted a resident.

The investigation substantiated the allegation that the facility did not permit the resident to return after a psychiatric emergency hold, violating the requirement to provide 30 days' written notice before changes. Deficiencies were issued related to residents' personal rights.

The complaint alleged that staff unlawfully evicted a resident who was placed on a 51/50 hold at Harbor UCLA Psychiatric Emergency Room. The facility refused to accept the resident back, which was substantiated by interviews and record reviews.

An unannounced complaint investigation was conducted to address the allegation that staff unlawfully evicted a resident.

The investigation found that the facility did not provide the required 30 days' written notice before eviction and refused to accept the resident back after hospitalization, substantiating the allegation. Deficiencies were issued and plans for correction were developed.

The complaint alleged that staff unlawfully evicted a resident who was placed on a 51/50 hold at Harbor UCLA Psychiatric Emergency Room. The facility refused to accept the resident back after hospitalization, violating eviction notice requirements. The allegation was substantiated based on interviews and record reviews.

An unannounced required annual inspection was conducted using the full CAREs Inspection Tool to evaluate compliance with licensing requirements for the facility serving elderly developmentally disabled adults ages 60 and above.

The inspection found the facility to be in good condition with no deficiencies issued. Resident rooms, common areas, and safety equipment were all compliant with regulations, and all required documentation was maintained and in order.

The visit was an unannounced complaint investigation triggered by an allegation that a resident sustained multiple unexplained bruises.

The investigation included interviews, record reviews, and observations. Although bruises were noted on the resident, there was insufficient evidence to substantiate the allegation, and no deficiencies were cited.

The allegation was that a resident sustained multiple unexplained bruises. The investigation found bruises on the resident's arms, but the resident denied knowledge of the cause. Medication side effects and family member actions were noted as possible factors. Staff and resident interviews were inconclusive. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

An unannounced complaint investigation visit was conducted in response to allegations that staff were not permitting residents to have visitors, receive phone calls, and were not safeguarding residents' belongings.

The investigation found no preponderance of evidence to substantiate the allegations. Interviews with staff and residents indicated that residents were allowed visitors and phone calls, and staff generally safeguarded residents' belongings. The allegations were determined to be unsubstantiated and no deficiencies were cited.

The complaint alleged that staff were not permitting residents to have visitors or receive phone calls, and were not safeguarding residents' belongings. The investigation included interviews with staff and residents, review of records, and observation. All allegations were found to be unsubstantiated.

The inspection was an unannounced complaint investigation visit conducted in response to allegations that a resident developed pressure injuries while in care and that staff did not seek medical attention for the resident.

The investigation substantiated that due to facility staff neglect, Resident 1 developed stage 2 and stage 3 pressure injuries which were not properly treated or assessed by medical professionals. Staff failed to ensure timely medical attention for the resident, posing a potential health and safety risk to all residents in care.

The complaint was substantiated based on evidence including medical records, interviews with staff and residents, and facility documentation. The allegations involved neglect resulting in pressure injuries and failure to seek medical care for Resident 1.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-06-24 regarding visitor restrictions, lack of hygiene products, food provision, staff hitting residents, and assistance with showers.

After interviews with staff, residents, and the administrator, as well as record reviews and observations, there was insufficient evidence to substantiate any of the allegations. All allegations were deemed unsubstantiated.

The complaint investigation addressed multiple allegations including staff not allowing visitors, not supplying hygiene products, not providing food, staff hitting residents, and not assisting residents in the shower. All allegations were found unsubstantiated due to lack of sufficient evidence.

An unannounced complaint investigation was conducted following a complaint received on 04/18/2024 alleging that facility staff did not treat a resident with dignity.

The investigation substantiated the allegation that staff did not treat a resident with dignity and respect, including bullying and lack of confidentiality. Interviews with staff and residents showed a majority reported respectful treatment, but evidence supported the complaint. Deficiencies were issued related to personal rights violations.

The complaint alleged that staff were disrespectful, bullied a resident after a police report request, failed to maintain confidentiality, and caused the resident to request transfer due to safety concerns. The allegation was substantiated based on interviews and record review.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-04-05 regarding visitation restrictions and unexplained bruises on a resident.

The investigation found no preponderance of evidence to substantiate the allegations. Staff were reported to restrict visitation in certain circumstances but residents and most staff confirmed visitors were allowed. A bruise was observed on a resident's wrist but staff were unaware and the bruise was later healed. Overall, the allegations were unsubstantiated.

The complaint involved two allegations: 1) Facility staff not allowing visitation, and 2) Resident having unexplained bruises. Both allegations were investigated through interviews with staff and residents, record reviews, and observations. The findings concluded the allegations were unsubstantiated due to lack of sufficient evidence.

The visit was an unannounced complaint investigation triggered by an allegation of lack of supervision resulting in a physical altercation between residents.

The investigation found that although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation was unsubstantiated.

Allegation: Lack of supervision resulted in physical altercation between residents. Interviews with staff and residents showed differing opinions on supervision. The allegation was determined to be unsubstantiated due to insufficient evidence.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff refused to provide a resident with medications.

The investigation substantiated the allegation that staff refused to provide a resident with blood pressure medication despite it being available and the resident being able to manage their own medication. Deficiencies were cited related to this issue. Another allegation that staff did not treat residents with dignity and respect was unsubstantiated based on interviews and record reviews.

The complaint investigation was substantiated regarding staff refusal to provide medication to a resident. The allegation that staff did not treat residents with dignity and respect was unsubstantiated.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations that facility staff did not allow a resident access to make and receive private phone calls.

The investigation substantiated the allegation that the facility administrator confiscated a resident's personal cellphone and unplugged the landline phone in the resident's private room, which posed an immediate health and safety risk. Interviews with staff and residents and record reviews supported these findings.

The complaint alleged that facility staff did not allow resident access to make and receive private phone calls. The investigation found that the administrator confiscated the resident's personal cellphone and unplugged the landline phone. The allegation was substantiated based on interviews and record review.

An unannounced complaint investigation visit was conducted in response to allegations received on 2024-04-05 regarding staff stealing a resident's ID, failure to ensure residents attend medical appointments, improper medication administration, and restricting resident communication with family members.

The investigation included interviews with staff and residents, file reviews, and observation. All allegations were found to be unsubstantiated due to lack of preponderance of evidence supporting the claims.

The complaint included four allegations: 1) Facility staff stole ID from resident; 2) Facility is not ensuring resident goes to medical appointments; 3) Facility is not administering medications as ordered by doctor; 4) Facility is not allowing resident to communicate with family members. After investigation, all allegations were determined to be unsubstantiated.

An unannounced annual required inspection was conducted using the CARE Inspection Tool to evaluate compliance with licensing regulations for the facility.

The facility was found to be clean, well-maintained, and compliant with regulations. No deficiencies were observed during the visit. Safety equipment and supplies were in good condition, and medications were securely stored.

The inspection was an unannounced complaint investigation visit triggered by an allegation of illegal eviction received on 2024-01-29.

The investigation found insufficient evidence to substantiate the allegation of illegal eviction of resident R-1. The resident was transferred due to a need for a higher level of care following several incidents, including one requiring hospitalization.

Allegation: Illegal Eviction. The complainant alleged the facility illegally evicted resident R-1. The investigation included interviews with staff and residents and review of records. The allegation was found unsubstantiated due to lack of preponderance of evidence.

An unannounced complaint investigation was conducted regarding the allegation that staff did not release resident's personal items upon discharge.

The investigation included interviews with staff, residents, and the Director, as well as review of resident files and photographs of the resident's room. The allegation was found to be unsubstantiated as the resident's belongings were still in the assigned room and staff confirmed that personal items are released upon discharge.

The complaint alleged that staff did not release resident’s personal items upon discharge. Interviews with staff and residents, and photographic evidence showed the belongings were still in the room and accessible. The allegation was unsubstantiated.

The visit was an unannounced complaint investigation triggered by allegations received on 2023-11-21 regarding staff leaving a resident unattended in a wheelchair and staff not meeting residents' needs.

The investigation found no sufficient evidence to substantiate the allegations. Residents and staff interviews indicated that residents are not left unattended in wheelchairs for extended periods and that residents' needs are generally met. The resident involved was found to have violated facility smoking rules and did not pay the required deposit for smoking privileges.

The complaint involved two allegations: 1) Staff left a resident unattended in a wheelchair for an extended period, and 2) Staff did not meet residents' needs. Both allegations were found to be unsubstantiated based on interviews with residents and staff and review of records.

An unannounced complaint investigation visit was conducted in response to allegations that facility staff did not arrange for medical care as needed and did not dispense medications as prescribed.

The investigation found insufficient evidence to substantiate the allegations. Residents and staff interviews, as well as record reviews, indicated that medical care was arranged as needed and medications were dispensed as prescribed. Therefore, the allegations were determined to be unsubstantiated.

The complaint alleged that facility staff failed to arrange for medical care and did not dispense medications as prescribed. The investigation included interviews with residents and staff, review of medical and medication records, and verification with the prescribing psychiatrist. The allegations were found to be unsubstantiated due to lack of sufficient evidence.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff withheld a resident's personal mobility device.

The investigation found sufficient evidence to substantiate the allegation that staff withheld a resident's personal mobility device. The facility's Community Rules prohibited motorized scooters and wheelchairs for safety reasons, but these rules were not approved by the licensing division. Interviews with residents and staff confirmed the restriction on use of personal mobility devices.

The complaint alleged that staff withheld a resident's personal mobility device. The allegation was substantiated based on interviews and record reviews. The preponderance of evidence standard was met.

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2023-12-15 regarding resident care and facility conditions at Gardena Retirement Center.

The investigation found no sufficient evidence to substantiate any of the allegations, including restrictions on residents leaving the facility, failure to ensure medical appointments attendance, inadequate meals, room disrepair, and mismanagement of resident funds.

The complaint investigation was unsubstantiated. Allegations included staff not allowing residents to leave, failure to ensure medical appointments, inadequate meals, room disrepair, and mismanagement of resident funds. Interviews, file reviews, and observations did not corroborate these allegations.

The visit was an unannounced case management incident inspection conducted due to incident reports received on 12/05/2023 regarding excessive drinking by residents.

The inspection found violations of residents' personal rights, including making a resident sit outside until sober and confining another resident to their room, which posed immediate health and safety risks. Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapters 1 and 6.

The visit was triggered by incident reports received on 12/05/2023 regarding excessive drinking by residents. The complaint was substantiated by findings of violations of personal rights.

The visit was an unannounced complaint investigation triggered by an allegation that due to lack of supervision, a resident got into a physical altercation with another resident.

The investigation included interviews with residents and staff, and review of facility records. It was found that an altercation did occur on 10/4/23, but there was insufficient evidence to substantiate the allegation of lack of supervision. The allegation was determined to be unsubstantiated.

The complaint alleged lack of supervision leading to a physical altercation between residents. Interviews with 10 residents and 9 staff, and review of incident reports and medical records were conducted. Three staff confirmed the incident occurred. One resident was hospitalized. The allegation was unsubstantiated due to insufficient evidence.

An unannounced complaint investigation visit was conducted in response to allegations that staff were not assisting residents at the facility.

Based on interviews, file review, and observations, there was insufficient evidence to substantiate the allegation that staff were not assisting residents. No deficiencies were cited during the visit.

The complaint alleged that staff were not assisting residents. The investigation included interviews with staff, residents, and family, as well as review of relevant documents. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2023-09-05 regarding medication errors, denial of private visits, and restriction of personal possessions at the facility.

The investigation found insufficient evidence to substantiate any of the allegations. Interviews with residents and staff, as well as records review, did not support claims of medication errors, denial of private visits, or restriction of personal possessions. All allegations were determined to be unsubstantiated.

The complaint investigation addressed three allegations: 1) Facility staff dispensed medications not prescribed to residents, 2) Facility staff did not allow residents to have private visits with family, and 3) Facility staff did not allow residents to keep their own personal possessions. All allegations were found unsubstantiated due to insufficient evidence.

The visit was a Case Management - Other type of unannounced visit to discuss a 30 day Eviction Notice for resident R1 and review related documentation.

The Licensing Program Analyst met with the Administrator Susana Fuentes to review eviction notices and statements of balances due for resident R1. The resident's belongings were observed still in the room. The Administrator agreed to provide requested email and pay history documentation.

The visit was an unannounced complaint investigation conducted to investigate allegations including staff stealing residents' identification cards, staff interfering with residents' visitation, and staff threatening residents in care.

The investigation found insufficient evidence to substantiate any of the allegations. Interviews with staff and residents, as well as document reviews, did not support the claims of stolen IDs, interference with visitation, or threats to residents. No deficiencies were cited during the visit.

The complaint investigation was unsubstantiated. Allegations included staff stealing residents' identification cards, interfering with residents' visitation, and threatening residents. Interviews and document reviews did not provide sufficient evidence to prove the allegations.

The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-06-02 regarding allegations of staff not responding to residents' calls for assistance, not safeguarding residents' belongings, not allowing personal phone calls, and refusing visitors.

The investigation included interviews with staff and residents and a tour of the facility. All allegations were found to be unsubstantiated due to insufficient evidence to prove the alleged violations occurred. No deficiencies were cited during the visit.

The complaint involved four allegations: 1) Staff not responding to residents' calls for assistance; 2) Staff did not safeguard residents' belongings; 3) Staff not allowing residents personal phone calls; 4) Staff refusing to allow residents to have visitors. All allegations were investigated through interviews and document review and were found unsubstantiated.

The visit was a Case Management - Other type of unannounced inspection involving discussion with the Administrator regarding a 30 day Eviction Notice for a resident.

The Licensing Program Analyst met with the Administrator to review eviction notices and observed that the resident's belongings were still in the room. Copies of eviction notices and related correspondence were received from the Administrator.

An unannounced complaint investigation visit was conducted in response to an allegation of unlawful eviction of a resident at Gardena Retirement Center.

The investigation included observations, staff interviews, and document reviews. The allegation of unlawful eviction was found to be unsubstantiated as there was insufficient evidence to prove the eviction occurred; the resident's name was still on the roster and personal belongings remained in the room.

The complaint alleged that resident R1 was unlawfully evicted from the facility. Interviews with the resident and facility administrator, along with observations, showed that the resident was currently in a nursing home but continued to pay rent and had not been served eviction notices. The allegation was unsubstantiated.

An unannounced annual required inspection was conducted using the CARE Inspection Tool to evaluate compliance with licensing regulations for the Gardena Retirement Center.

The facility was found to be sanitary, appropriately furnished, and in compliance with Title 22 regulations. No deficiencies were observed and no citations were issued during this inspection.

The inspection was an unannounced complaint investigation triggered by an allegation that the facility was not providing a safe environment for residents.

The investigation substantiated the allegation that the facility was not providing a safe environment, specifically noting that a resident who was unable to leave the premises unassisted was walking back and forth in the driveway where delivery trucks were backing in, posing a potential safety risk.

The complaint alleged that a resident was repeatedly walking back and forth in the driveway while a delivery truck was backing in, posing a risk of harm. Interviews with residents, staff, and the administrator, as well as review of the resident's physician report, supported the allegation. The resident was not able to leave the facility unassisted, confirming the safety risk. The allegation was substantiated.

The visit was an unannounced 10-day complaint investigation conducted in response to a complaint received on 03/09/2023 regarding an allegation of illegal eviction at the facility.

The investigation substantiated the allegation of illegal eviction due to the administrator's failure to serve the eviction notice to the licensing agency within the required 5-day timeframe as mandated by Title 22 regulations, despite the eviction notice containing all required components.

The complaint investigation was substantiated. The allegation was illegal eviction due to failure to timely provide a copy of the eviction notice to the licensing agency as required by Title 22 regulations.

The inspection visit was conducted as a complaint investigation regarding an allegation of unlawful eviction at Gardena Retirement Center.

The investigation found that the allegation of unlawful eviction was unsubstantiated. The facility was unable to provide proper care for the resident due to medical needs requiring a higher level of care. No deficiencies were observed or cited.

The complaint alleged that the Administrator refused to accept a resident back into the facility. The investigation included interviews, a facility tour, and review of medical and admission documents. The allegation was found unsubstantiated based on evidence that the resident's care needs exceeded the facility's capabilities.

An unannounced complaint investigation was conducted due to allegations that a resident sustained an unexplained injury while in care and that staff did not seek medical care for the resident in a timely manner.

The investigation substantiated that the resident sustained a deep and gaping wound due to neglect and lack of care and supervision. Staff failed to properly assess and timely report the injury, delaying medical care. The facility was cited for violations related to observation of residents and personnel training.

The complaint investigation was substantiated. The resident sustained an unexplained injury while in care, and staff did not seek medical care in a timely manner. Evidence included interviews, record reviews, and hospital records confirming the injury and delayed response.

An unannounced complaint investigation visit was conducted in response to an allegation of unlawful eviction at Gardena Retirement Center.

The investigation included observations, staff interviews, and review of facility records. The allegation of unlawful eviction was found to be unsubstantiated as the resident was present in their room and no eviction notices were found.

The complaint alleged that the facility unlawfully evicted a resident (R1). The allegation was unsubstantiated after investigation, including interviews with the administrator and observation of the resident in their room.

The visit was an unannounced complaint investigation conducted in response to an allegation that staff were retaining a resident who requires a higher level of care.

The investigation found no sufficient evidence to support the allegation. Interviews with staff and residents indicated that the resident in question was placed by her doctor, is on hospice care with regular nurse and doctor visits, and the facility staff provide necessary care and supervision. The allegation was deemed unsubstantiated and no deficiencies were cited.

The complaint alleged that staff were retaining a resident requiring a higher level of care. The allegation was investigated through interviews with staff and residents, review of records, and observation. The allegation was found to be unsubstantiated due to lack of sufficient evidence.

The inspection was an unannounced complaint investigation triggered by a complaint alleging the facility was not providing a safe environment for residents, specifically concerning residents walking in the driveway where a truck was backing up.

The investigation substantiated the allegation that residents who were not able to leave on their own were walking back and forth in the driveway, posing a potential health and safety risk. Staff and resident interviews, along with record reviews, supported this finding.

The complaint alleged a resident was walking with a walker repeatedly in the driveway where a truck was backing up, creating a safety hazard. The allegation was substantiated based on interviews with residents, staff, and the administrator, as well as record reviews indicating residents with confusion and disorientation walking unsupervised.

The visit was an unannounced complaint investigation conducted in response to a complaint received on 2022-02-23 alleging multiple issues including residents being left in soiled diapers, untimely call bell responses, unmet hygiene needs, residents left in bed, missed meals, rough handling, lack of assistance, and insufficient staffing.

The investigation found no sufficient evidence to support any of the allegations. Interviews with residents and staff, as well as facility record reviews, indicated that the facility met care standards and staffing levels. All allegations were determined to be unsubstantiated.

The complaint investigation was unannounced and addressed nine allegations related to resident care and staffing. After interviews with residents (R1-R7), staff (S1-S7), and facility administrators, and review of records, the department found no evidence to substantiate the allegations. The allegations included staff leaving residents in soiled diapers, not answering call bells timely, not meeting hygiene needs, leaving residents in bed, not providing lunch, rough handling, not assisting residents, and insufficient staffing. The findings concluded all allegations were unsubstantiated.

An unannounced complaint investigation was conducted in response to multiple allegations received on 10/11/2021 regarding medication administration, incontinence care, personal care item restrictions, mask provision, universal precautions, and toilet paper use at the facility.

The investigation found no sufficient evidence to support any of the allegations. The department concluded that staff administered medications as prescribed, assisted with incontinence care, allowed residents to keep personal care items, provided adequate masks, followed universal precautions, and did not limit residents' use of toilet paper.

The complaint investigation was unsubstantiated. Allegations included staff not administering medications as prescribed, not assisting with incontinence care, restricting personal care items, inadequate mask provision, failure to follow universal precautions, and limiting toilet paper use. After interviews, document reviews, and observations, no evidence supported these claims.

An unannounced complaint investigation visit was conducted due to an allegation that the facility was not following COVID-19 protocols.

The investigation, including interviews with staff and residents and inspection of the facility and documents, found that the facility follows COVID-19 protocols, including weekly testing and mask encouragement. The allegation was unsubstantiated due to lack of sufficient evidence.

The complaint alleged that the facility was not following COVID-19 protocols. The investigation found no sufficient evidence to support this allegation, and it was determined to be unsubstantiated.

An unannounced complaint investigation visit was conducted in response to allegations that the facility illegally evicted a resident and retaliated against a resident.

The investigation found the allegations of illegal eviction and retaliation to be unsubstantiated based on interviews, observations, and review of court and facility documentation.

The complaint alleged that the facility illegally evicted a resident and retaliated against the resident. Interviews with the resident, staff, and review of court paperwork showed the eviction was court-ordered due to violations of house rules and unpaid rent. No evidence of retaliation or improper eviction was found. The allegations were unsubstantiated.

An unannounced complaint investigation visit was conducted in response to an allegation that the facility was not providing a comfortable environment for residents in care.

Interviews with staff and residents indicated that the facility is providing a comfortable environment, residents have personal rights including listening to music on their cellphones without disturbing others, and no harassment or loud music issues were found. The allegation was deemed unsubstantiated due to insufficient evidence.

The complaint alleged the facility was not providing a comfortable environment for residents. The investigation found no substantiation of the allegation; staff and residents denied the claims, and no deficiencies were cited.

An unannounced complaint investigation was conducted to investigate allegations that staff did not seek timely medical attention for a resident in care and that staff refused to let a resident back into the facility.

The investigation found no sufficient evidence to support the allegations. Interviews with staff and residents, facility inspection, and record reviews indicated that medical attention was not denied and residents were not refused reentry. The allegations were determined to be unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included staff not seeking timely medical attention for a resident and staff refusing to let a resident back in. Interviews with staff and residents, as well as facility observations, did not support these allegations.

The visit was an unannounced complaint investigation conducted in response to allegations that the facility was not preventing the spread of COVID-19 and that residents were confined to their bedrooms.

The investigation found no sufficient evidence to support the allegations. The facility was following COVID-19 protocols including weekly testing, isolation procedures, and mask usage. Residents were not confined to their bedrooms as some chose to leave their rooms despite staff redirection.

The complaint investigation was unannounced and based on allegations received on 02/09/2022. The allegations were unsubstantiated after investigation, with no evidence found to support claims that the facility was not preventing COVID-19 spread or confining residents to their bedrooms.

The visit was an unannounced complaint investigation conducted in response to allegations received on 2022-01-03 regarding staff administering unprescribed medication to a resident and the facility having pests.

The investigation found no evidence to support the allegations that staff administered unprescribed medication to residents or that the facility had pests. Interviews with staff and residents, review of medication administration records, and exterminator reports showed no substantiation of the complaints.

The complaint investigation was unsubstantiated. Allegations included staff administering unprescribed medication and presence of pests (bed bugs). The department found insufficient evidence to support either allegation after interviews, record reviews, and inspections.

The visit was an unannounced complaint investigation regarding an allegation that a resident sustained burns while in care.

The investigation revealed that the resident sustained severe accidental burns from hot water in a bathtub but was independent and did not request staff assistance for bathing. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.

The complaint was that a resident sustained burns while in care. The allegation was investigated through interviews with the resident, staff, and review of facility and medical records. The resident took full responsibility for the injury and did not request assistance. The allegation was unsubstantiated.

The visit was an unannounced complaint investigation initiated due to an allegation that staff were not providing adequate activities to residents.

The investigation included interviews with staff and residents, observation of activities, and review of records. The evidence did not substantiate the allegation, as activities were observed and residents reported encouragement to participate.

The allegation was that staff were not providing adequate activities to residents. The complaint was investigated and found to be unsubstantiated based on interviews, observations, and records review.

The visit was an unannounced complaint investigation to determine if the facility was allowing residents to work at the facility, as alleged in a complaint received on 2022-05-16.

The investigation found that some residents assist staff with simple tasks as an activity and not as paid employees. Interviews with staff and residents confirmed this practice but no evidence was found that residents were employed or paid. The allegation was determined to be unsubstantiated.

The complaint alleged that residents were assisting staff with duties without being fingerprint cleared and were working at the facility. The investigation found no sufficient evidence to substantiate the allegation, concluding it was unsubstantiated.

The visit was an unannounced complaint investigation conducted to investigate the allegation that staff did not prevent a resident from disturbing another resident in care.

The investigation found insufficient evidence to substantiate the allegation that staff failed to prevent a resident from disturbing another. Interviews with residents and staff indicated that disturbances were not common and were addressed when they occurred. The allegation was determined to be unsubstantiated.

The complaint alleged that facility residents were yelling and playing loud music and that staff did nothing when it was reported. Interviews with residents and staff did not support these claims, leading to an unsubstantiated finding.

An unannounced complaint investigation visit was conducted in response to an allegation that staff did not respond to a resident's call button in a timely manner.

The investigation found that the facility uses a call button and alert system for emergencies and non-emergencies, with staff responding promptly and informing residents of wait times. Interviews with residents and staff indicated no widespread concerns about call button response times. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that staff did not respond to a resident's call button in a timely manner. The investigation included interviews with residents, staff, and the administrator, as well as review of relevant records. The complaint was found to be unsubstantiated.

The inspection visit was an unannounced complaint investigation triggered by an allegation that a resident was being financially abused while in care.

The investigation included interviews with residents, staff, and the administrator, as well as review of financial and medical records. The allegation was found to be unsubstantiated due to lack of preponderance of evidence, with no discrepancies found in the resident's trust fund account and no reports of concerns from other residents or staff.

The complaint alleged that a resident was being financially abused while in care. The investigation revealed confusion by the resident regarding trust fund account transactions but no evidence of mismanagement. The facility discontinued management of the resident's trust fund and issued reimbursement. Interviews with residents and staff did not reveal concerns. The allegation was unsubstantiated.

An unannounced annual required visit was conducted with a primary focus on Infection Control measures using the CARE Inspection Tool.

The facility was found to be in compliance with infection control practices, including screening protocols, PPE supply, and sanitation. No deficiencies were identified during this annual inspection.

An unannounced complaint investigation was conducted in response to an allegation that staff speak inappropriately to residents.

The investigation included interviews with the administrator, staff, and residents, as well as review of relevant training and rosters. The Licensing Program Analyst was unable to verify the allegation and found insufficient evidence to support it, resulting in an unsubstantiated finding.

Allegation that staff speak inappropriately to residents was investigated and found unsubstantiated due to lack of sufficient evidence.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 03/17/2022 regarding resident wandering and facility security issues.

The investigation substantiated that a resident with dementia wandered outside the facility unattended due to an unmanned front desk and a disabled auditory alarm on the backdoor. Other allegations regarding inappropriate staff behavior, denial of heat requests, and denial of television installation were unsubstantiated.

The complaint investigation was substantiated for allegations that a resident wandered from the facility and that the facility was not properly secured. Other allegations about inappropriate staff communication, denial of heat requests, and denial of television installation were unsubstantiated.

An unannounced complaint investigation was conducted following a complaint received on 2022-04-06 alleging that residents were not afforded comfortable accommodations and that staff did not ensure residents were taking universal precautions.

The investigation included interviews with staff and residents, review of records, and a plant inspection. The allegations were found to be unsubstantiated as there was insufficient evidence to prove the alleged violations occurred.

The complaint involved two allegations: 1) residents not being afforded comfortable accommodations, and 2) staff not ensuring residents were taking universal precautions. Interviews with residents and staff indicated residents felt comfortable and cared for, and staff described appropriate handling of catheter care and cleaning procedures. The preponderance of evidence standard was not met, resulting in unsubstantiated findings.

An unannounced complaint investigation was conducted due to an allegation that facility staff was not adequately supervising residents in care.

The investigation substantiated the allegation that a staff member's four-year-old child was allowed to roam the facility unsupervised and pushed resident #1 in a wheelchair without staff supervision, posing a potential health and safety risk to residents.

The complaint alleged inadequate supervision of residents, specifically that a staff member's child was allowed to push resident #1 in a wheelchair unsupervised. The allegation was substantiated based on interviews, video surveillance, and record reviews.

An unannounced complaint investigation was conducted in response to an allegation that a resident was not provided an appointment to see the onsite nurse.

The investigation included interviews with residents, staff, and review of medical records. It was found that the resident had been seen monthly by the nurse in 2021 and 2022, and no resident was denied access to doctor or nurse services. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

Allegation: Resident not provided appointment to see onsite nurse. The allegation was investigated through interviews with resident R1, staff S1-S5, residents R2-R8, and nurse W1, as well as review of medical records. The allegation was unsubstantiated.

The visit was an unannounced complaint investigation triggered by a complaint received on 03/15/2022 regarding a mat/rug in disrepair at the facility.

The investigation substantiated the complaint that a rubber floor mat with curled up edges located in front of the glass doors was in disrepair and posed a potential tripping hazard. The mat was removed by maintenance during the investigation. Staff and residents were interviewed with mixed awareness of the issue, and the facility was cited for not keeping areas free of hazards.

The complaint was substantiated. The allegation was that a mat/rug was in disrepair with curled up edges posing a tripping hazard. The investigation included interviews with staff and residents, review of records, and a physical plant walkthrough. The mat was removed during the investigation.

The inspection was conducted as an unannounced complaint investigation visit triggered by allegations received on 12/23/2021 regarding inadequate staffing and lack of activities for residents at the facility.

The investigation found insufficient evidence to substantiate the allegations. Interviews with staff and residents, observations, and records review indicated that the facility had adequate staffing and provided activities for residents, including in-person activities resumed after COVID restrictions were lifted.

The complaint alleged inadequate staffing and lack of activities for residents. The investigation included interviews with staff, residents, and the administrator; review of staffing schedules and activity calendars; and observations of resident activities. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

The visit was a Case Management - Deficiencies inspection initiated to document deficiencies observed during the investigation of a complaint with complaint control number 11-AS-20220228091331.

The inspection found that the hot water temperature in resident rooms was excessively high, ranging from 130.2 to 135.9 degrees Fahrenheit, exceeding the regulatory maximum of 120 degrees Fahrenheit, posing an immediate health and safety risk to residents. The facility administrator took immediate action to lower the water heaters and contacted maintenance and a plumber.

The visit was conducted as part of a complaint investigation with complaint control number 11-AS-20220228091331. The complaint involved unsafe hot water temperatures.

An unannounced complaint investigation visit was conducted in response to allegations that the facility was not following COVID-19 guidelines, a resident was being illegally evicted, and the facility was retaliating against a resident for making complaints.

The investigation included interviews with staff and residents, inspection of the facility, and review of records. The allegations were found to be unsubstantiated due to insufficient evidence to prove violations. The facility was following COVID-19 guidelines, eviction was approved due to behavioral issues, and no retaliation was observed.

The complaint involved three allegations: failure to follow COVID-19 guidelines, illegal eviction of a resident, and retaliation against a resident for complaints. The investigation found no sufficient evidence to substantiate these allegations, and they were deemed unsubstantiated.

The visit was an unannounced complaint investigation conducted in response to an allegation received on 12/17/2021 that smoke alarms were in disrepair at the facility.

The investigation included interviews with staff and residents, inspection of the facility's fire safety systems, and review of maintenance records. No sufficient evidence was found to substantiate the allegation that smoke alarms were in disrepair; the complaint was determined to be unsubstantiated.

The complaint alleged that two smoke detectors in the hallway had been beeping for two weeks. Interviews with staff and residents, observations, and records review did not support the allegation. The complaint was unsubstantiated.

The inspection was an unannounced complaint investigation visit conducted due to allegations including resident harassment, facility retaining residents requiring higher level of care, staff restraining residents, lack of activities, unanswered phones, and unresponsiveness to call buttons.

The investigation substantiated the allegation of resident harassment between residents. Other allegations regarding retaining residents needing higher care, staff restraining residents, lack of activities, unanswered phones, and call button responsiveness were found to be unsubstantiated based on interviews, observations, and records review.

The complaint investigation was triggered by allegations that a resident was harassing another resident. The investigation found sufficient evidence to substantiate this allegation. Other allegations about facility care levels, staff restraint, activities, phone answering, and call button response were unsubstantiated.

The inspection was an unannounced complaint investigation conducted to investigate allegations that the facility had a leaking pipe.

The investigation found no sufficient evidence to support the allegation of a leaking pipe. The plumbing issue was addressed promptly, and interviews with residents and staff did not confirm the complaint. The allegation was determined to be unsubstantiated.

The complaint alleged that a pipe at the facility was leaking feces. The investigation included a tour, interviews with staff and residents, and review of plumbing repair invoices. The allegation was found unsubstantiated due to lack of evidence.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-01-31 regarding transportation to medical appointments, resident injury while in care, and adequacy of services provided to residents.

The investigation found no sufficient evidence to support any of the allegations. The facility does not provide transportation but assists residents in arranging it; no evidence of resident injury while in care was found; and staff provided adequate assistance with bathing and grooming. The allegations were determined to be unsubstantiated.

The complaint included three allegations: 1) Facility does not provide transportation to medical appointments; 2) Resident was injured while in care; 3) Staff did not provide adequate services to resident in care. After investigation including interviews with staff and residents, review of records and incident reports, all allegations were found unsubstantiated.

An unannounced complaint investigation was conducted in response to an allegation that staff did not administer medication to a resident.

The investigation found no sufficient evidence to support the allegation that staff failed to administer medication to the resident. Interviews, record reviews, and observations indicated that medications were administered as required, and the allegation was unsubstantiated.

The complaint alleged that staff did not administer evening medication to resident R1. The investigation included interviews with staff and residents, review of medication administration records, and facility inspection. The allegation was found to be unsubstantiated.

The visit was an unannounced complaint investigation triggered by allegations that the facility was not assisting residents with transportation needs and did not have required postings in public view.

The investigation substantiated that the facility was not assisting residents with transportation to medical appointments as required by the admission agreement policy, and that required facility license postings were not consistently displayed in public view due to ongoing repairs and past removal incidents.

The complaint investigation was substantiated. The facility was found not to be assisting residents with transportation needs per admission agreement policy and was not maintaining required postings in public view. The investigation included interviews with 6 staff members and 6 residents, document reviews, and observations.

The visit was an unannounced complaint investigation triggered by an allegation that staff do not respond to resident's call button in a timely manner.

The investigation included interviews with staff and residents, review of documents, and observation of call button stations and video footage. The Licensing Program Analyst found no sufficient evidence to support the allegation, concluding the complaint was unsubstantiated.

The complaint alleged that staff do not respond to resident's call button in a timely manner. After investigation including interviews with 8 staff members and 6 residents, document review, and video observation, the allegation was found unsubstantiated due to lack of preponderance of evidence.

An unannounced Case Management - Deficiencies visit was conducted to document deficiencies observed during investigation of a complaint with control number 11-AS-20211228090259.

During the investigation, it was noted that staff members (Staff 1 through Staff 4) did not have current CPR/First Aid training, posing a potential health and safety risk for clients in care.

The visit was triggered by a complaint investigation with control number 11-AS-20211228090259.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 09/09/2021 regarding multiple allegations about the facility's care and environment.

The investigation found no sufficient evidence to substantiate any of the allegations, including staff failing to meet residents' needs, resident wandering, inappropriate staff communication, inadequate food service, unsafe environment, and facility disrepair. The allegations were determined to be unsubstantiated.

The complaint included allegations that staff were failing to meet residents' needs, a resident wandered away while in care, staff spoke to residents inappropriately, staff failed to provide adequate food service, the facility failed to provide a safe and comfortable environment, and the facility was in disrepair. The investigation included interviews with staff and residents, review of incident reports and facility documents, and observations. All allegations were found unsubstantiated due to lack of sufficient evidence.

An unannounced complaint investigation was conducted following a complaint received on 10/04/2021 alleging staff handled a resident roughly and that a resident was being harassed by another resident.

The investigation found no sufficient evidence to support the allegations that staff handled a resident in a rough manner or that a resident was being harassed by another resident. The allegations were determined to be unsubstantiated.

The complaint involved two allegations: 1) staff handled a resident in a rough manner, and 2) a resident was being harassed by another resident. After interviews with residents, staff, and the administrator, and review of records and observations, the allegations were found unsubstantiated due to lack of evidence. The harassment allegation had been previously substantiated in an earlier complaint and was not re-investigated.

The visit was an unannounced complaint investigation initiated due to an allegation of illegal eviction received on 2021-11-29.

The investigation found insufficient evidence to support the allegation of illegal eviction. The allegation was determined to be unsubstantiated after inspection, interviews, and document review.

The complaint alleged illegal eviction. The investigation was unsubstantiated due to lack of preponderance of evidence to prove the alleged violation occurred.

The visit was an unannounced complaint investigation conducted to investigate allegations that residents' meals were late and that a resident's bed was in disrepair.

The investigation found no sufficient evidence to support the allegations that residents' meals were late or that residents' beds were in disrepair. Interviews with staff and residents, facility inspection, and record reviews did not substantiate the complaints.

The complaint investigation was unsubstantiated. Allegations included residents' meals being late and a resident's bed being in disrepair. The investigation included interviews with staff and residents, inspection of beds, and review of records. No evidence was found to support the allegations.

The visit was an unannounced investigation of a complaint alleging that a resident was harassing another resident at the facility.

The investigation substantiated the allegation of resident harassment based on witness statements, video evidence, and interviews with residents and staff. The facility failed to ensure residents were free from intimidation or abuse, posing a potential health and safety risk.

The complaint alleged that resident R2 was harassing resident R1 by calling several residents names and making derogatory remarks. The allegation was substantiated based on witness statements, video evidence, and interviews with residents and staff.

An unannounced complaint investigation visit was conducted in response to allegations received on 08/09/2021 regarding resident malnutrition, sexual abuse, physical abuse, incorrect medication administration, and unmet hygiene needs.

The investigation found no sufficient evidence to support any of the allegations. Interviews with residents and staff, review of records, and observations indicated that residents received adequate food, were not sexually or physically abused, medications were administered correctly, and hygiene needs were met.

The complaint investigation was unsubstantiated for all allegations including resident malnutrition, staff sexual abuse, physical abuse, incorrect medication administration, and unmet hygiene needs.

The visit was an unannounced complaint investigation conducted to investigate the allegation that the facility is in disrepair.

The investigation found no sufficient evidence to support the allegation that the facility is in disrepair. Toilets and elevators were found to be in working order based on inspections and interviews with residents and staff. The allegation was determined to be unsubstantiated.

The complaint alleged that toilets on the first floor had been out of order for three weeks and that the elevator was faulty. The investigation included interviews with residents and staff, inspection of facility grounds, and review of records. The allegation was unsubstantiated.

An unannounced complaint investigation visit was conducted in response to multiple allegations received on 2021-06-29 regarding staff interfering with residents' hygiene needs, medication administration, transportation services, accommodations, eviction threats, and care supervision.

The investigation found no sufficient evidence to substantiate any of the allegations. Interviews with residents, staff, and the administrator, as well as facility inspections and record reviews, indicated that the facility was providing appropriate care, accommodations, transportation assistance, and medication administration policies were followed. The allegations were determined to be unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included staff interfering with hygiene needs, not administering medications as needed, not providing transportation, not providing comfortable accommodations, threatening eviction, and improper care and supervision. The Department found no sufficient evidence to support these allegations.

The inspection was an unannounced complaint investigation visit triggered by allegations that a resident sustained multiple falls while in care and that facility staff did not seek medical attention in a timely manner.

The allegation that the resident sustained multiple falls while in care was substantiated due to lack of a fall prevention plan despite the resident's fall risk. The allegation that staff did not seek medical attention in a timely manner was unsubstantiated as staff called a non-emergency ambulance immediately but experienced delays due to ambulance availability.

The complaint involved allegations that a resident sustained multiple falls while in care and that facility staff did not seek medical attention in a timely manner. The first allegation was substantiated; the second was unsubstantiated.

An unannounced complaint investigation visit was conducted in response to allegations that the facility was not adhering to the admissions agreement and that a resident was not being allowed to smoke.

The investigation found no sufficient evidence to support the allegations. The admissions agreements did not indicate private room status, and residents were allowed to smoke in designated areas. The allegations were determined to be unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included the facility not adhering to the admissions agreement regarding private room assignment and a resident not being allowed to smoke. Interviews with residents and staff, review of records, and observations found no evidence to support these allegations.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2021-07-06 regarding missed medical appointments, refusal of transportation for medical appointments, failure to meet residents' hygiene needs, and insufficient staffing.

The investigation found insufficient evidence to substantiate allegations related to missed medical appointments, refusal to provide transportation, and failure to meet hygiene needs. However, the allegation of insufficient staffing to meet residents' needs was substantiated, with evidence showing the facility lacked sufficient staff, posing a potential health risk.

The complaint investigation was triggered by allegations that a resident missed medical appointments due to lack of transportation, staff refused to provide transportation, staff failed to meet residents' hygiene needs, and there was insufficient staffing to meet residents' needs. The first three allegations were found unsubstantiated, while the insufficient staffing allegation was substantiated.

The visit was an unannounced complaint investigation conducted in response to allegations received on 07/16/2021 regarding staff interference with residents' daily living functions and residents not being accorded dignity in their relationships with staff.

The investigation included interviews with residents and staff, a tour of the facility, and review of records. The preponderance of evidence standard was not met for either allegation, resulting in both allegations being unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included staff interfering with residents' daily living functions and residents not being accorded dignity. Interviews with 7 residents and 5 staff members indicated no interference or lack of dignity. The evidence did not prove the alleged violations occurred.

The visit was an unannounced case management inspection regarding an incident reported to the Community Care Licensing on 2021-06-04.

No deficiencies were cited at the time of the visit; however, additional investigation was required including analysis of records obtained and follow-up interviews.

The visit was triggered by an incident complaint reported on 2021-06-04. The investigation was ongoing with no substantiation or deficiencies cited at the time of the report.

The inspection was an unannounced complaint investigation conducted to investigate the allegation that food is not of good quality or quantity at the facility.

The investigation included a tour of the facility, interviews with the administrator, residents, and staff, and review of menus and food supply. The evidence did not substantiate the allegation; residents generally reported receiving enough food and good quality meals, and staff confirmed adequate food provision.

The complaint alleged that food was not of good quality or quantity. The investigation found no preponderance of evidence to prove the allegation, and it was determined to be unsubstantiated.