Inspection Reports for The Palms at San Lauren

An unannounced case management visit was conducted to discuss a recent incident report involving a resident who eloped from the facility by climbing out of a bedroom window.

The resident eloped by removing a window screen and climbing out, posing an immediate risk to health and safety. The facility responded by returning the resident, increasing room check frequency from every two hours to every hour, and installing new metal window locks on memory care windows. A citation under Title 22 was issued and a plan of correction was implemented and cleared during the visit.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2025-02-11 regarding resident care issues including lack of showers, rough handling, untimely response to calls, improper billing, mail handling, supervision, and diet adherence.

The investigation substantiated the allegation that residents did not have hot water and access to showers for over 7 days in February 2025, posing a potential health risk. Other allegations including rough handling, untimely assistance, improper billing, mail handling, lack of supervision, and diet noncompliance were found to be unsubstantiated or unfounded based on interviews and record reviews.

The complaint investigation was substantiated for the allegation that residents lacked hot water and shower access for over 7 days in February 2025. Other allegations including rough handling of residents, untimely response to calls, charging for services not rendered, opening residents' mail, lack of supervision leading to resident altercation, and failure to follow special diets were unsubstantiated or unfounded.

The visit was an unannounced required annual inspection conducted by Licensing Program Analysts to evaluate compliance with licensing requirements.

The facility was found to be in compliance with all licensing requirements with no deficiencies cited. Observations included proper lighting, furnishings, operational safety equipment, and appropriate food storage.

Unannounced Plan of Correction visit conducted to follow up on the 02/29/25 complaint visit.

The facility developed a memo draft to inform residents about building issues affecting daily living, with plans to document meetings and distribute information to all residents. The Plan of Correction from 02/19/25 is cleared.

The inspection was an unannounced Case Management visit conducted for the purpose of an annual continuation visit.

The Licensing Program Analysts conducted a health and safety check, reviewed resident and staff files, finding that 3 of 6 resident files had required documentation while 3 of 3 resident files were missing updated TB testing. Three of five staff files had required documentation. Technical assistance was provided.

An unannounced complaint investigation visit was conducted due to a complaint received on 2025-02-11 regarding the facility being without hot water in the residential section.

The investigation substantiated that the facility did not have hot water available to residents for over 7 days, posing a potential risk to their health, safety, and personal rights. A deficiency was cited under CCR 87303(a) for failure to maintain the facility in a clean, safe, sanitary, and good repair condition.

Complaint was substantiated based on interviews, observations, and records review. The allegation that the facility was without hot water in the residential section was confirmed.

The visit was an unannounced case management visit based on a self-reported incident involving a resident.

No deficiencies were cited during the visit. Licensing Program Analysts reviewed requested documents related to the incident and toured the facility, noting recently completed new flooring.

The inspection was an unannounced annual continuation visit conducted to review resident and staff records for compliance.

The Licensing Program Analyst reviewed a sample of resident and staff records and found them complete with required documentation and updated training records. No deficiencies were cited during the visit.

The visit was an unannounced case management inspection conducted due to an incident involving a physical altercation between two residents in the memory care unit.

The incident involved Resident R1 and Resident R2, with R1 receiving PRN medication for agitation and R2 receiving first aid. Both families were notified, and no deficiencies were cited during the visit.

The visit was an unannounced required annual inspection conducted by Licensing Program Analyst L. Salazar to evaluate the facility's compliance with regulatory standards.

The facility was found to be in compliance with no deficiencies cited. Observations included proper lighting, furnishings, safety measures, food storage, and required postings. Fire extinguishers and first aid kits were properly maintained.

Unannounced complaint investigation visit conducted in response to multiple allegations regarding resident care including pressure injuries, rough handling, lack of medical attention, inadequate food service, and call button access.

The investigation found the allegations to be unfounded after reviewing resident records, interviewing staff and family, and observing the facility. The facility was found to be in compliance with the hospice care plan and no deficiencies were cited.

Complaint allegations included multiple pressure injuries due to staff neglect, rough handling, failure to seek medical attention, denial of hospice care, inadequate food service, leaving resident in soiled diapers, and failure to respond to or provide access to call button. The complaint was determined to be unfounded.

Unannounced visit/investigation of a complaint alleging that staff do not provide the resident with water.

The complaint was found to be unfounded after review of Hospice Care notes and interviews with the Administrator and a resident's relative. No deficiencies were cited during the visit.

Complaint was unsubstantiated and dismissed as unfounded, meaning the allegation was false or without reasonable basis.

The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident was being left in soiled linens/diapers.

The investigation found the complaint to be unfounded after reviewing records, interviews, and hospice care notes. No deficiencies were cited, and the allegation was determined to be false or without reasonable basis.

The complaint alleged that a resident was left in soiled linens/diapers. The resident was receiving hospice care and had refused care and medication. Multiple care conferences documented that the allegations were not true. The complaint was found to be unfounded.

An unannounced complaint investigation was conducted following allegations that facility staff were not present at the facility and did not respond to a resident's pull chord for assistance.

The investigation substantiated the allegations that one staff member was not present at the facility for approximately 30 minutes and that staff did not answer pull chords for residents in care. A civil penalty was issued for absence of supervision.

The complaint was substantiated based on the preponderance of evidence standard. The allegations involved staff absence and failure to respond to resident pull chords. A civil penalty was issued and additional deficiencies were referred to Case Management.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not answering call bells timely.

The investigation found that staff response times to call bells were delayed, with documented instances of staff taking over 4 minutes to respond and one incident where staff were absent for approximately 30 minutes, posing a potential health and safety risk. The allegation was substantiated based on interviews, record reviews, and evidence.

The complaint was substantiated. The allegation was that staff were not answering call bells timely. Evidence included a timed response of 4 minutes and 32 seconds, a Kern Fire Department record of no staff present for 30 minutes, and witness interviews confirming delayed responses.

The visit was an unannounced complaint investigation to deliver findings for two complaints (AS-20230321111428 and 24-AS-20230330093440).

Deficiencies were found related to the administrator's failure to provide requested records for the signal system from 3/15/23 to 3/31/23 and the facility's failure to produce an incident report for a resident (R1) regarding an incident in one of the complaints. Additionally, the facility did not report emergency services responding for R1 as required.

The investigation was triggered by complaints AS-20230321111428 and 24-AS-20230330093440. The facility was unable to provide an incident report for resident R1 related to complaint 24-AS-20230330093440, and the complaint was substantiated by the findings.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2022-12-09 regarding staff not cleaning residents' rooms timely, not meeting feeding needs, insufficient staffing, medication mismanagement, and failure to safeguard resident's personal property.

The investigation substantiated allegations that staff did not clean Resident R1's room timely and failed to meet feeding needs as documented. Other allegations regarding insufficient staffing, medication mismanagement, and safeguarding personal property were found to be unfounded. Deficiencies related to infection control and functional assessment were cited with plans of correction required.

The complaint investigation was substantiated for allegations that staff did not clean residents' rooms timely and did not meet feeding needs of Resident R1. Other allegations of insufficient staffing, medication mismanagement, and failure to safeguard personal property were found to be unfounded.

An unannounced complaint investigation was conducted in response to allegations that facility staff were not meeting residents' hygiene, dietary needs, cleaning of rooms and linens, and repositioning of residents.

The investigation found the complaint to be unfounded after observations, interviews, and records review showed the resident's room and bedding were clean, the resident was able to reposition their bed independently, and dietary needs were being met according to hospice records and facility menus. No deficiencies were cited.

The complaint was found to be unfounded, meaning the allegations were false or without reasonable basis, and the complaint was dismissed.

An unannounced complaint investigation was conducted in response to allegations received on 01/09/2023 regarding medication administration timeliness and staff intimidation of a resident.

The investigation found the complaint to be unfounded after interviews, records review, and observation, with no deficiencies cited.

The complaint was found to be unfounded, meaning the allegations were false or without reasonable basis, and the complaint was dismissed.

The visit was an unannounced required annual inspection conducted to evaluate compliance with licensing regulations at the facility.

The facility was found to be in compliance with no deficiencies cited. Observations included proper lighting, furnishings, safety measures, operational fire extinguishers, locked medications, and adequate food supplies.

An unannounced Infection Control Inspection was conducted as a required 1-year visit to assess compliance with infection control standards.

The facility was found clean with no fire clearance issues, adequate supplies of medications, food, cleaning, and PPE were observed, and staff and residents were compliant with mask-wearing and social distancing. No deficiencies were issued.

The inspection was conducted as an unannounced complaint investigation regarding an allegation that staff do not prevent a resident from wandering while in care.

The complaint was found to be unfounded after investigation, with no deficiencies issued. Interviews and record reviews showed the resident was not found wandering outside the facility and had never left unsupervised.

The complaint alleging staff do not prevent a resident from wandering while in care was investigated and found to be unfounded, meaning the allegation was false, could not have happened, or was without reasonable basis.

An unannounced Case Management inspection was conducted to investigate complaint number 24-AS-20211012140617 regarding an incident involving a resident exhibiting aggressive behavior.

The facility failed to submit an incident report after a resident (R1) exhibited aggressive behavior requiring police intervention and hospital transport, which poses a potential health and safety risk to persons in care.

Investigation of complaint number 24-AS-20211012140617 found the facility did not file an incident report after police responded to a call for aggressive behavior by resident R1.

The visit was conducted as a Case Management-Deficiencies inspection via telephone due to COVID-19 precautions, following a complaint investigation regarding staff not wearing face coverings while providing care.

The investigation found that on 10/21/2020, the Administrator failed to protect clients' personal rights by allowing staff to not wear face coverings while providing care, violating official government orders. A deficiency was cited based on video evidence.

The visit was complaint-related, substantiated by video evidence showing staff not wearing face coverings as required, violating personal rights and health safety regulations.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 11/20/2020 alleging that staff failed to treat a resident with dignity and respect.

The investigation found that on 10/21/2020, staff recorded a resident's behavior without consent and failed to appropriately redirect the resident, which substantiated the allegation of failure to treat the resident with dignity and respect.

The complaint was substantiated based on staff interviews, personnel records review, and video observation. The allegation was that staff failed to treat a resident with dignity and respect by recording the resident without consent and laughing instead of redirecting the resident appropriately.

The inspection was an unannounced complaint investigation visit conducted in response to multiple complaints received on 03/24/2020 regarding resident care issues including incontinence needs, showering needs, rough handling, injuries, supervision, food quantity, and pest presence.

The investigation substantiated that staff failed to meet residents' incontinence and showering needs, posing an immediate health and safety risk. Other allegations such as rough handling, injuries, supervision, food quantity, and presence of ants were found unsubstantiated or unfounded. A deficiency was cited related to residents not being changed or showered as scheduled.

The complaint investigation was substantiated for failure to meet residents' incontinence and showering needs. Other complaints regarding rough handling, injuries, supervision, food quantity, and facility ants were unsubstantiated or unfounded.