complaint·July 16, 2021

The Department investigated and found that R1 sustained severe bruising due to improper handling during transfers. From documents obtained and reviewed, R1 has a history of bruising and taking baby Aspirin daily. R1’s responsible party had discussions with staff and administrator regarding R1’s propensity to bruise easily and effective handling practices to minimize R1 bruising. However, even after these discussions, R1 sustained severe bruising because of staff’s failure to utilize proper handling techniques. R1 reported the bruises were from staff grabbing her on the legs and arms possibly to keep her from falling. W1 stated that R1 is able to stand by herself without assistance. W1 witnessed an incident when R1 was lying in bed and taking a while to get out of bed, staff grabbed R1’s arm to help pull her up off the bed. Interview with S1 revealed that an Amazon echo dot device was found in R1’s room. S1 stated that the device was removed on 4/28/2020 and returned to R1 on 4/30/2020. S1 stated that the device had audio capability which violated facility’s admission agreement. However, S1 later discovered that the device’s audio capability was disconnected. In the email correspondence with R1’s responsible party dated 4/28/2020, S1 stated the device was removed from R1’s room on 4/27/2020. Based on the department’s investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED . California Code of Regulations, Title 22 is being cited on the LIC 9099D. A $500.00 immediate civil penalty is being assessed on this day. Civil penalty determination related to serious bodily injury is pending. Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided.