complaint·February 27, 2025

Page 2 During the course of investigation, LPA obtained copy of resident roster and conducted interviews. LPA also reviewed the Unusual Incident Report (UIRs) and SOC341s submitted by the facility to Community Care Licensing (CCL) for R1 and R2 which showed the abuse were reported to CCL past the required timeline of 48 hours and not reported to the Ombudsman and local law enforcement. These were discussed with the ED. ED stated the other alleged abuse incident relating to resident (R3) was reported to CCL on which a copy of SOC341 was provided by ED on this same day, 2/27/25. LPA and ED spoke to staff (S1) who stated she did not submit the LIC624 for R3 to CCL. LPA interviewed the Ombudsman (OMD) on 2/21/25. OMD stated not receiving copies of SOC341s for R1 and R2. Based on interviews and review of documents, the preponderance of evidence has been met, therefore, the allegation of staff do not ensure reporting requirements are followed is substantiated. Deficiency is cited from Title 22 California Code of Regulations, and listed on 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.