complaint·November 18, 2025

The investigation consisted of; review of requested/obtained documents; staff roster, client roster, R1’s face sheet, R1 placement agency contact, R1’s physician report dated 09/09/2025, R1’s medical/health summary dated 08/19/2021, a court ordered examination/competency evaluation dated 03/02/2015, R1’s third party caregivers. Review of R1’s court order dated 04/09/2015. Interviews with staff, residents and witnesses and LPA observations. NOTE: Due to the displacement of individuals from 2025 Eaton Fires, The facility, has been housing residents on an emergency basis, including R1. Regarding the allegation: Staff is yelling at residents. It is alleged that staff are yelling at residents in care. Five (5) of five (5) staff interviewed stated they are not yelling at residents in care. Three (3) of five (5) staff admit to raising their tone of voice to redirect residents, but never to degrade residents. Staff interviewed stated that R1 was displaced due to the Eaton Fire and R1 was placed at the facility on a temporary basis, since, 01/08/25. Staff #4-#5 (S4, S5) are from R1’s prior facility, which is also owned by the licensee. S4 and S5 are employed at R1’s former facility and perform wellness checks on their displaced residents on a weekly basis. Per LPA’s interview with W2, W2 recalls sitting with R1 in facility dining hall when S5 approached R1 about toileting concerns that were occurring during the night. W2 stated witnessing S5 humiliate and ridicule R1 in front of other residents by approaching R1 and offering R1 adult briefs. S5 and R1 began to argue, R1 called S5 degrading names and S5 then yelled at R1. According to W2, several other residents were present and observed the argument. Four (4) of seven (7) residents interviewed stated a few staff have become indifferent since the Eaton Fires and have taken their frustration upon residents. Based on LPAs interviews which were conducted and records reviewed, the preponderance of evidence standard has been met, therefore the a found Above allegation is be substantiated. Citation is being issued on a LIC 9099D, California Code of Regulations, Title 22, Division 6 & Chapter number 8, are being cited on the attached LIC 9099D. Exit interview conducted with Administrator Kim Commodore and a copy of LIC 9099, LIC 9099C and LIC 9099D. Appeals rights discussed and a copy of appeal right were provided to Administrator Kim Commodore. Note Cite Section 87468.1 Personal Rights