complaint·March 27, 2025

ALLEGATION: Staff did not properly report an incident involving the residents INVESTIGATION FINDING: Substantiated During investigation, the department conducted interviews of facility staff (ADM), residents (R1, R2), reporting party (RP) and reviewed R1 & R2 documents. On 03/24/25 at 10AM, LPA interviewed reporting party (RP) who stated that R1 and R2 had a physical altercation the evening of 02/16/25 and also the next morning before breakfast in their bedroom resulting in R2 sustaining bruising in his right cheek and a cut to his nose. On 03/27/25 at 1PM, ADM confirmed with LPA that they failed to timely report the incident to Community Care Licensing (CCLD) and Ombudsman (OMB) within the required 48 hours timeline. Based on observations and interviews which were conducted and record review(s), the department has substantiated the allegation that staff did not properly report an incident involving residents. The preponderance of evidence standard has been met. Therefore, the above allegation was found to be substantiated. Continued on the next page, LIC 9099-C pg2 ALLEGATION: Staff did not prevent the residents from engaging in a physical altercation INVESTIGATION FINDING: Substantiated On 03/24/25 at 10:30AM, LPA interviewed reporting party (RP) who stated that R1 and R2 had a physical altercation on the evening of 02/16/25 resulting in R1 sustaining bruises to his face and a cut to his nose. On 03/27/25 at 1PM, LPA interviewed administrator (ADM) who stated that R1 & R2 had an argument inside their bedroom again in the morning before breakfast. ADM stated R1 punched R2 in the face which bruised his right cheek and cut his nose. On 03/27/25 at 2:35PM, R1 and R2 both confirmed with LPA that no staff redirected them when the incidents occurred inside their bedroom. ADM stated that she did not know about the incident until she noticed R2’s bruised face and cut nose the next morning during breakfast. ADM stated R2 did not want to go to the hospital to treat his nose and bruises. ADM treated him with cold compress and was offered ibuprofen which he refused. With the residents' consent, ADM moved R2 to another bedroom with another roommate to avoid reoccurrence of the incident. R1 remained in his room without any roommate. On 02/18/25, ADM stated R1 was re-evaluated by his primary care physician and was prescribed increased Olanzapine medication. Based on observations and interviews which were conducted and record review(s), the department has substantiated the allegation that staff did not prevent the residents from engaging in a physical altercation. The preponderance of evidence standard has been met. Therefore, the above allegation was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.