Inspection Reports for The Kensington Sierra Madre

An unannounced Initial 10-Day complaint investigation visit was conducted regarding the allegation that staff do not safeguard the residents' confidential information.

The investigation found no preponderance of evidence to support the allegation. Staff, residents, and witnesses denied that staff provided residents' confidential information to third parties or were involved in selling residents' personal property. The allegation was determined to be unsubstantiated.

The complaint alleged that staff did not safeguard residents' confidential information by allowing a third party business access to a resident’s personal information, resulting in the sale of the resident’s personal property. The investigation included interviews with staff, residents, witnesses, and review of documents. The allegation was found unsubstantiated due to lack of evidence.

The inspection was an unannounced complaint investigation visit conducted due to an allegation that the facility did not have a designated substitute administrator.

The investigation found that all seven staff interviewed denied the allegation and confirmed management was always available via phone and email. Four residents also denied the allegation, stating management was easily accessible. Documentation showed designated substitute administrators were authorized during the administrator's temporary absence. The allegation was unsubstantiated and no violations were observed.

The complaint alleged that the facility did not have a designated substitute administrator and that no management was visible or available during a recent tour. The allegation was unsubstantiated based on staff and resident interviews, documentation review, and observations.

The inspection was an unannounced complaint investigation visit conducted in response to an allegation that a resident was being physically abused while in care.

The investigation substantiated the allegation that staff member S1 physically abused resident R1 by pushing them down into bed, handling them roughly during dressing, and forcefully sitting them down. No injuries were found, but S1's conduct was found to pose an immediate threat to residents' health and safety, resulting in termination of S1's employment and issuance of a Type A deficiency.

The complaint investigation was substantiated. The allegation was that a resident was physically abused by staff in the dementia wing. Evidence included staff interviews, record reviews, and a police incident report. The facility terminated the staff member involved. The police report and responsible party interview did not corroborate the allegation, but the preponderance of evidence supported substantiation.

The inspection was an unannounced Case Management Visit-Deficiency conducted on 05/16/2025, stemming from a subsequent complaint investigation regarding medication administration practices.

Staff camouflaged resident #1's medications into chocolate pudding without the resident's consent or a physician's order, violating regulations and posing an immediate risk to the health, safety, and personal rights of persons in care. A Type A deficiency was issued for this violation.

The visit was triggered by a complaint investigation (Control Number: 28-AS-20250429162024) related to medication administration practices involving resident #1.

An unannounced complaint investigation visit was conducted to investigate allegations that the facility was in disrepair and that staff did not provide adequate supervision to residents in care.

The investigation found that the front entrance door was functional and repaired promptly after a mechanical malfunction, and that the facility had adequate staff providing supervision to residents. Interviews and record reviews did not corroborate the allegations, resulting in the complaints being unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included facility disrepair and inadequate staff supervision. Evidence showed the entrance door was repaired within 24 hours and staff coverage was adequate with 45-50 employees per shift. Police visits related to complaints did not disrupt operations and no further investigation was reported.

The inspection was an unannounced 10-day complaint investigation visit triggered by an allegation that the licensee was falsely advertising, promoting, and holding themselves out as providing special care.

After interviews with staff and residents, review of promotional materials, and facility tour, there was insufficient evidence to substantiate the allegation. Staff and residents denied the claims, and the services listed in promotional materials were confirmed to be provided.

The allegation was that the licensee was falsely advertising and promoting special care, with staff making misleading statements and behaving unprofessionally. Five out of five staff and seven out of seven residents interviewed denied the allegation. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The inspection was a required annual unannounced visit to evaluate compliance with licensing regulations and facility operations.

The facility was found to be in compliance with infection control, operational requirements, physical plant safety, staffing, personnel records, resident records, residents' rights, planned activities, food service, incidental medical and dental care, disaster preparedness, and care for residents with special health needs. No deficiencies were cited during this inspection.

An unannounced complaint investigation was conducted regarding allegations that facility staff were not providing adequate transportation services to residents, specifically that multiple medical appointments were turned down or rescheduled due to staff misuse of the company vehicle.

The investigation included interviews with staff and residents, review of transportation logs and related documents, and found no evidence to support the allegation. Staff and residents denied cancellations or rescheduling due to vehicle unavailability, and the transportation log showed no such disruptions. The allegation was determined to be unsubstantiated.

The complaint alleged that between 01/13/2025 and 01/22/2025, multiple medical appointments were turned down or rescheduled due to a staff member using the medical transportation company vehicle for personal purposes. The investigation found insufficient evidence to substantiate this allegation.

The visit was an unannounced complaint investigation triggered by allegations that a resident sustained unexplained injuries while in care and that staff did not seek medical assistance in a timely manner.

The investigation substantiated that the resident sustained fractured ribs, a wrist injury, and a minor toe injury while in care, and the facility failed to seek timely medical assistance. The facility also failed to develop a care plan addressing the resident as a fall risk despite multiple risk factors.

The complaint was substantiated. The resident sustained unexplained injuries including fractured ribs, a wrist injury, and a minor toe injury. The facility did not seek medical assistance in a timely manner. The resident was not identified as a fall risk despite having multiple risk factors such as confusion, use of a walker, advanced age, and psychotropic medication use.

The inspection was an unannounced complaint investigation visit conducted in response to allegations that a resident sustained unexplained injuries while in care and that staff did not seek medical assistance in a timely manner, as well as allegations regarding failure to notify the resident's authorized representative of an injury and unmet hygiene needs.

The investigation substantiated that the resident sustained fractured ribs, a wrist injury, and a minor toe injury while in care, and that the facility did not seek timely medical assistance. The resident was not identified as a fall risk despite multiple risk factors. The allegation that staff failed to notify the resident's authorized representative was unsubstantiated, as a voicemail was left. The allegation regarding unmet hygiene needs was also unsubstantiated. An immediate civil penalty of $500 was issued due to the substantiated deficiencies.

The complaint investigation was substantiated for allegations that the resident sustained unexplained injuries and that staff did not seek medical assistance in a timely manner. The allegations that staff did not notify the resident's authorized representative and that the resident's hygiene needs were not met were unsubstantiated.

The Licensing Program Analyst conducted the required annual unannounced inspection to evaluate compliance with regulatory requirements for the facility licensed to serve elderly residents.

The facility was generally compliant with infection control, operational requirements, physical plant safety, staffing, personnel records, resident records, residents' rights, planned activities, food service, disaster preparedness, and care for residents with special health needs. One deficiency was cited regarding an unlocked medication cart posing a safety risk, which was immediately corrected by staff locking the cart.

An unannounced required Annual Visit focusing on COVID-19 Infection Control Practices was conducted to evaluate compliance with infection control and facility regulations.

The facility was found to be in compliance with all regulations, including proper water temperatures, clean and equipped bathrooms, operational signal systems, safe food storage, and fire safety measures. No deficiencies were observed during the visit.

The visit was an unannounced complaint investigation conducted to investigate allegations that facility staff dropped a resident resulting in injury, that the resident had a pressure injury while in care, and that the resident had torn, ripped, or stretched out clothing.

The investigation found that the resident had a fall but was not dropped by staff, sustained a small scrap on the knee not diagnosed as a pressure injury, and had older clothing but was not pulled from clothing during care. All allegations were unsubstantiated due to lack of evidence.

The complaint investigation was unsubstantiated. Allegations included a resident being dropped causing injury, having a pressure injury, and having torn clothing. Interviews with staff, the resident, and family, as well as record reviews, did not substantiate the allegations.

The inspection was a Required - 1 Year unannounced visit to evaluate compliance with regulations, including infection control, physical plant safety, medication, and food supplies.

The facility was found to have deficiencies related to hot water temperatures exceeding Title 22 Regulation guidelines, presence of toxic substances accessible to residents, and missing prescribed PRN medications for a resident. These deficiencies posed immediate health and safety risks but citations were cleared at the time of visit.