Complaint·September 11, 2025

The investigation consisted of the following: On 07/02/25, LPA requested the staff and resident rosters. LPA reviewed service records for resident #1 (R1) and requested copies of the following documents: Physician’s Report, Advance Health Care Directive Form, Admission Agreement, Medication List dated 07/01/25, Resident Care Assessment Form, Appraisal Needs and Services Plan, Preplacement Appraisal Information, Personal Care Program Form, and 2-Hour Rounds Check Policy Form. Additionally, LPA conducted interviews with staff #1-#5 (S1-S5), witness #1 (W1), and residents #2-#5 (R2-R5) and attempted to interview R1. Furthermore, LPA and Steve Cho conducted a tour of the facility. On 09/11/25, LPA Gonzalez received the following documents for R1: Medication Administration Record (MAR) for the months of July and August 2025, and staff notes. The investigation revealed the following: Allegation: Resident is being physically abused while in care. It is being 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 body checks are conducted daily and any bruising or change in condition is communicated to both the primary care physician and families 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 and attempted to interview R1 but was unable to because the resident was asleep in their room and did not wish to be interviewed. 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 09/11/25, LPA conducted a review of records and revealed the following: Physician’s Report (dated: 07/08/25) stated that R1’s ambulatory status is bedridden based upon both physical and mental conditions. Continued on LIC9099-C Report also stated that R1 has a history of skin condition or breakdown due to thin skin related to age. A review of the MAR for the months of July, and August 2025 noted that certain prescribed medications may contribute to increased bruising. There was no incident reports reporting any physical abuse, scars or bruising. 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. 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 called the Personal Care Program, which is offered for an additional fee. If the family denies that extra coverage, then staff 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 and attempted to interview R1 but was unable to because the resident was asleep in their room and did not wish to be interviewed. 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. Continued on LIC9099-C On 09/11/25, LPA Gonzalez conducted a review of records and observed that there were no incident reports reporting any physical abuse, scars or bruising. 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.