Follow-up on corrections·September 18, 2025

Licensing Program Analyst (Ernand Dabuet) made an unannounced visit to the facility and was greeted by caregiver (Marilyn Nery). The Administrator (Mark Loo) was contacted by phone and explained the purpose of this visit is to deliver a generated Case Management – Deficiencies, evaluation report in conjunction with Complaint Control #11-AS-20191113101336 due to the following observations: This investigation revealed that Resident #1 was restrained to the bedrails utilizing pieces of cloth sheets and shirts. The cloth restraints were placed around the resident’s wrists – while the resident was wearing gloves. Staff #1 admitted the purpose of the restraints were to prevent Resident #1 from removing the Foley catheter and scratching its wounds; as the resident would get agitated. Staff #1 expressed the necessity to occasionally restrain Resident #1 in different positions in order to prevent the resident from placing pressure on its wounds. On several occasions, Witness #1 observed Resident #1 tied to the bed rails in this same manner and would instruct Staff #1 to immediately remove the restraints. It seemed to be a reoccurring event requiring Witness #1 to repeatedly order Staff #1 to remove these restraints from Resident #1. Based on the evidence gathered and interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation PERSONAL RIGHTS: Resident was restrained by the hands to the bedrails is found to be SUBSTANTIATED . According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency was observed and a citation issued (ref. LIC 9099D). An exit interview was conducted with (Mark Loo), and copy of the Complaint Report and Appeal Rights were provided to caregiver (Marilyn Nery).