complaint·November 15, 2022

and a staff member has a hard time redirecting R1. All staff members informed LPA that they were aware of R1 having the propensity to assault other residents in the facility. LPA was informed by all staff members that on 11/6/22 without any warning R1 assaulted and punch R2 in the face and no staff was around to stop the incident. Moreover, interviews with one (1) out of five (5) residents revealed that about three weeks ago R1 attempted to enter R3's room in a very aggressive way and caused R3 to be frightened of R1 ever since. In addition, interview with a MedTech revealed that R1's medical condition/mood changes around 2:30-3:00pm, and R1 becomes more combative. MedTech informed LPA that R1's medications have been changed, but the aggressive behavior towards the staff members and other residents' is still there. Interview with a Memory Care Director confirmed that R1 punched R2 in the face without provocation and caused bleeding on R2's face and 911 was called immediately. Memory Care Director informed LPA that the family took R1 to ER on 11/06/22 and once R1's medications are changed and or adjusted R1 will return to the community. Lastly, LPA reviewed one (1) incident report submitted on 10/12/22 and two (2) incident reports submitted on 10/16/22 where it was indicated that R1 assaulted a resident and two (2) staff members without any warnings. Based on interviews and document review, during the course of the investigation the facility failed to protect residents from being assaulted by R1. Therefore, there is sufficient evidence to conclude that the above allegation is Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC9099-D): Exit interview conducted, copy of report, citations and appeal rights issued.