complaint·July 3, 2025

Allegation: Staff inappropriately pushed a resident while in care Investigation Finding: Substantiated During investigation, LPA conducted interviews with, reporting party (RP), third party witness (W1) and facility staff (ED, S1, S2) and reviewed resident (R1) documents. Review of R1’s records showed he was first admitted at the facility on 02/28/24. R1 was assessed as having dementia, non-ambulatory and needs total assistance with bathing, dressing and behavioral expressions. LPA interviewed ED and W1 who confirmed that the incident occurred on 05/20 at 2PM wherein staff (S2) inappropriately pushed R1 against a wall while in care and that S2 was written up by ED. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated. Allegation: Staff inappropriately restrained a resident while in care Investigation Finding: Substantiated During investigation, LPA conducted interviews with, reporting party (RP), third party witness (W1) and facility staff (ED, S1, S2) and reviewed resident (R1) documents. RP and W1 stated that on 05/20/25 at 2PM, staff (S2) inappropriately restrained R1 by holding him against a wall. ED confirmed with LPA that staff (S2) was internally investigated and was written up for inappropriately restraining R1. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) 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 (POCs) 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 a copy of this report provided .