Complaint·July 2, 2025

The investigation revealed the following: Allegation: Resident is being physically abused while in care. It is being alleged that a resident is being abused on a regular basis and has been observed with multiple bruises and scars on their body. On 07/02/25, between 11:00 AM and 12:15 PM, LPA Gonzalez interviewed S1-S5. Based on interviews conducted, 5 out of 5 staff interviewed denied the allegation. 5 out of 5 staff interviewed stated that any bruises and cuts observed on a resident are reported to the med-tech and management, and are then monitored. 5 out of 5 staff interviewed stated that they treat residents with dignity and respect. On 07/02/25, between 01:35 PM and 2:18 PM, LPA Gonzalez interviewed R2-R5. Based on interviews conducted, 4 out of 5 residents denied the allegation. 4 out of 5 residents stated that staff have not physically abused them while in care. 4 out of 5 residents stated that they have not observed staff physically abusing a resident while in care. 4 out of 5 residents stated that staff treat them with dignity and respect. On 07/02/25, between 01:15 PM and 1:35 PM, LPA Gonzalez interviewed W1 and revealed that they appreciate the staff at this facility and all they do for the residents in care. W1 stated that the staff at this facility are very caring and go above and beyond for their family member, and the other residents in care. W1 stated that they understand that with age, the residents can become weak and fragile, and they are more prone to falls. W1 stated that they have no safety concerns for their family member at this facility, and that they have 100% confidence that the staff at this facility will provide the best care possible. Based on observation, records reviewed, and interviews conducted, the department did not find sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is unsubstantiated. Continued on LIC9099-C Allegation: Facility staff are not properly supervising residents who are a fall risk. It is being alleged that a resident has been observed with multiple bruises and scars on their body, and that staff claim the injuries are due to the resident falling out of their bed. It is also being alleged that a resident is often left alone in their room. On 07/02/25, between 11:00 AM and 12:15 PM, LPA Gonzalez interviewed S1-S5. Based on interviews conducted, 5 out of 5 staff interviewed denied the allegation. 5 out of 5 staff interviewed stated that they supervise and monitor residents who are considered a fall risk. 5 out of 5 staff stated that they check on the residents frequently and as needed depending on the residents’ needs. S1 stated that all residents are checked every two hours and as needed. S1 stated that when a resident is considered a fall risk after assessment, they recommend to the family or the party responsible for their special care service, which is called the Personal Care Program, for an additional fee. If the family denies that extra coverage, then we will continue to follow their 2-hour Rounds Check Policy which ensures that the residents are checked on every 2 hours when they are in their rooms. On 07/02/25, between 01:35 PM and 2:18 PM, LPA Gonzalez interviewed R2-R5. Based on interviews conducted, 4 out of 5 residents denied the allegation. 4 out of 5 residents stated that staff does supervise residents who are a fall risk. 4 out of 5 residents stated that they do not know if a resident has fallen down the stairs. 4 out of 5 residents stated that they are not left alone in their room for a long period of time. 4 out of 5 residents stated that staff treat them with dignity and respect. Based on observation, records reviewed, and interviews conducted, the department did not find sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report along with appeal rights was provided to Administrator, Steve Cho.