complaint·February 2, 2026

(Continued from LIC9099) At approximately 2:25 p.m., LPA reviewed and obtained copies of the following documents, including but not limited to: R1’s Physician’s Report, R1’s Appraisal, Staff #1’s (S1) job application, S1’s training records, and the Unusual Incident Report and SOC 341 the facility submitted to Community Care Licensing. R1 was not at the facility during todays visit. LPA's interviews with five (5) residents denied they had been treated roughly by staff members. LPA's interview with Staff #3 (S3) revealed R1 reported the incident to them. S3 then reviewed the video from that day and reported the incident to the assistant administrator. During LPA's interview with Staff #2 (S2) they stated they were asked to assist S1 with transferring R1 from the couch to a wheelchair, but did not witness, "R1 hit S1 or S1 hit R1 back" they maintained they did not witness either interaction and if S1 grabbed R1 it was without intention and without pressure. LPA's interview with S1 denies they handled R1 in a rough manner. According to S1 they held R1's arm down to prevent R1 from hitting staff or the other resident and they meant to "toss" the blanket to couch behind the client. LPA’s review of the video shows S1 and S2 struggling to assist R1 from the couch to a wheelchair, attempting at least three times before successfully placing R1 in the wheelchair. R1 is seen striking S1 in the face, after which S1 approaches R1 and grabs R1 by the right arm, because another resident stands in front of S1 and R1, LPA could observe R1’s head from side to side and part of R1's arm movement. S2 then tosses a blanket to R1, and R1 throws the blanket to the floor. S1 picks up the blanket from the floor and throws it over R1’s head and body before walking out of the room. R1 removes the blanket, and another resident is seen grabbing the blanket and shoving it onto R1’s face. S2 stops the interaction between R1 and the other resident, and then wheels R1 out of the room. According to the assistant administrator S1 was placed on Administrative leave pending an investigation and has been terminated as of 02/02/2026. Based on interviews conducted and video observed, this allegation is deemed SUBSTANTIATED at this time. Deficiency cited (refer to LIC9099-D). Exit interview conducted. Appeal Rights provided. A copy of the report was issued.