complaint·August 27, 2025

LPA interviewed twelve (12) out of ninety-four (94) residents who are available and seven (7) staff who were available at the facility. LPA obtained the following documents: physician report, admission records, LIC 601, resident roster, employee roster, and other relevant documents to the investigation at 2:30 PM. LPA interviewed R2 on 3/12/2025, the interview revealed that R1 would throw a cup of water, be aggressive, and yell racial slurs at R2. An interview with staff revealed that R2 is very friendly and sociable to everyone at the facility, and no other residents in the facility have any issues with R2. On 3/8/2025, 9-1-1 was called, and police arrived. Officers determined there was mutual battery with no arrest. During LPA interview with R1 on 3/12/2025 at 3:16 PM at the dining hall, LPA witnessed R2 tap R1 on the shoulder and greet R1. R1 got very upset, and yelled racial slurs and insults towards R2, calling R2 “monkey”. LPA witnessed no staff within reach to redirect R1 and R2. An interview with the executive director (S1), assisted living director (S2), and five (5) staff members revealed that R1 has been aggressive and angry towards R2 previously early this year. Record review for R1 revealed that R1 has been residing at the facility since 5/26/2021, and R2 has been residing at the facility since 1/10/2022. Staff are aware of the behavioral changes with R1, and the record review revealed that no resident re-appraisal was done. Based on interviews, observations, and record review, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.