complaint·February 19, 2026

The Investigation revealed the following: Allegation: Staff did not prevent resident from engaging in a physical altercation with another resident resulting in resident receiving multiple bruises It is being alleged that staff failed to implement necessary precautions to prevent an altercation between Resident 1 and Resident 2 (R1 and R2). LPA Shirley reviewed facility Special Incident Report dated 7/10/25, which noted the following: Staff 2 reported that on 7/9/25, R1 and R2 were arguing. R2 stated that while he was tying his shoes, R1 turned the bedroom light off. When R2 got up to turn the light back on, R1 hit him in the face with his shoe, so R2 hit him back. On 1/6/2026 LPA Shirely reviewed facility records and noted the following: physician’s reports for R1 and R2 (dated 1/1/25) indicate both have aggressive tendencies. LPA Shirley also reviewed the Appraisals and Needs and Services Plans for both residents and noted the plans do not mention anything about aggressive tendencies or plans to handle those tendencies for R1 or R2. The Department conducted interviews with facility administrator Susie Fuentes on 11/19/2025. During the interview, Fuentes stated that R1 and R2 had a history of altercations and that facility staff were aware. Furthermore, Administrator Fuentes stated staff are trained to immediately notify law enforcement regarding any suspected criminal act or physical abuse involving residents and that she felt better training should be provided for the staff. The department interviewed facility Staff 1 to staff 5(S1-S5), and of those interviewed, 2 out of 5 staff stated R1 and R2 had a previous history of aggressive speech or actions, with one of the staff adding that it had caused the residents to be moved to another room. The department also conducted interviews with facility residents, Resident 1 - Resident 5 (R1 – R5). Of those interviewed, 2 out of 5 stated R1 and R2 had a history of aggression Con'd on 9099-C towards each other. On 8/4/25, the department interviewed Witness 2 (W2), who reported that R1 spoke to them and alleged that a physical altercation had occurred at the facility involving their roommate. According to W2, R1 stated the roommate struck them in the back and further alleged that facility staff failed to intervene or take action when the incident occurred. The resident reportedly noted that this is the second or third similar occurrence involving the same roommate. Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. A Deficiencies was cited during today's visit. An exit interview was conducted, and plans of corrections were developed with the Administrator, Susie Fuentes. A copy of this report and appeals rights were provided.