complaint·September 15, 2025

The complainant alleged that staff was using medication to sedate resident #1 (R1) as a form of restraint. On 7.9.2025, between 8:40 AM and 9:10 AM, LPA requested and obtained copies of facility documents, including but not limited to the Staff Roster (LIC 500) and the Resident Roster (LIC 9020). In addition, documents from the file of R1 include the Physician’s Report (LIC 602A), Admission Agreement, appraisals, and the Centrally Stored Medication and Destruction Record (LIC 622). Between 9:39 and 10:30am, interviews were conducted with the Administrator and the Responsible Person (W1) for R1 via telephone, and two staff members who assist residents with self-administration of medications. Information obtained did not corroborate the allegation of chemical restraints and indicated medication assistance was conducted based on the doctor’s orders. At 10:30am, LPA conducted interviews with five (5) out of five (5) residents. All residents denied having been chemically restrained or having any knowledge of such a practice occurring at the facility. During the visit, LPA observed the activities of the five residents, which included watching television, taking a walk, and having breakfast. All residents appeared alert and active. The information obtained and the observations of the LPA did not support the allegation, which has been deemed Unsubstantiated at this time. Allegation #2: Resident was admitted to the facility without consent. Regarding the allegation, it was reported that R1 was admitted to the facility without family consent. To investigate the allegation, LPA Ngo-Castaneda conducted interviews with the facility administrator and staff #2 (S2), reviewed R1 records, and interviewed residents. The administrator and S1 confirmed that prior to admission, R1 had no family and had been appointed a public guardian. Between 10:30 and 11:30 LPA interviewed five (5) out of five (5) residents. The information obtained indicated the residents consented to their admission and are happy living at the facility. At 1:30pm LPA conducted a telephonic interview with the public guardian assigned to R1. The information obtained confirmed the public guardian had chosen the facility for R1 and authorized R1’s admission. The information obtained, observations, and record review of the LPA did not support the allegation which has been deemed Unsubstantiated at this time. Continue to LIC 9099-C Allegation #3: Resident was prevented from moving out of the facility. Regarding the allegation, it was reported that R1 was prevented from transferring out of the facility. To investigate the allegation, LPA Ngo-Castaneda conducted interviews with the facility administrator and staff #2 (S2), reviewed R1’s records, and interviewed residents. The administrator and S1 advised that at the time of the admission, R1 had no known family and had been appointed a public guardian. Between 10:30 and 11:30, LPA interviewed five (5) out of five (5) residents. The information obtained indicated that they were happy living at the facility. At 1:30pm LPA conducted a telephonic interview with the public guardian assigned to R1. The public guardian advised that there were currently no plans for R1 to move out or transfer. Based on the information obtained, observations, and record review of the LPA, the allegation which has been deemed Unsubstantiated at this time. No immediate health and safety hazards were observed during this visit. Exit interview conducted. Copy of report provided.