complaint·August 9, 2024

Allegation: Staff handled resident in a rough manner Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. LPA interviewed staff (ED) who confirmed that staff (S2) had an inappropriate physical interaction with resident (R1) during an incident that occurred on 02/25/24 between 7PM and 9PM. Review of video footage recorded during the incident on 02/25/24 showed S2 had inappropriate physical interaction with R1. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff handled resident in a rough manner was found to be substantiated. Allegation: Staff are provoking resident Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. LPA interviewed staff (S1) who confirmed that staff (S2) provoked resident (R1) during an incident that occurred on 02/25/24 when S2 refused to give R1 his request for extra juice and to have his cigarettes. Review of video footage recorded incident dated 02/25/24 showed R1 and S2 engaged in a physical/verbal altercation in the activities area. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff are provoking resident was found to be substantiated. Continued on next page, LIC 9099-C1 Allegation: Staff did not allow resident to have his cigarettes Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. LPA interviewed staff (ED, S1) who confirmed that staff (S2) provoked resident (R1) during an incident that occurred on 02/25/24 by not allowing him to have his cigarettes. Review of video footage recorded during the incident on 02/25/24 showed S2 engaged in a physical/verbal altercation with R1 and did not allow R1 to have his cigarettes. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not allow resident to have his cigarettes was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided. Allegation: Staff are mismanaging residents’ medication Investigation Finding: Unsubstantiated During investigation, LPA interviewed residents (R1, R2, R3, R4) who stated that staff assisted them with their medications daily. Review of centrally stored medication logs and medication administration records showed staff assisted residents with their daily medications as prescribed by their primary care physicians (PCP). Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff are mismanaging residents’ medication and found it to be unsubstantiated. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are mismanaging residents’ medication was found to be unsubstantiated. Exit interview conducted and a copy of this report provided.