complaint·April 1, 2026

The caregivers who were interviewed gave inconsistent information as to how R1 was transferred on October 12, 2025, which resulted in their injury. The two caregivers present were previously instructed to be in front of and behind R1 to assist with transferring. One of the caregivers stated she was on the left side of R1 when assisting. The other caregiver stated he was behind R1 as he was instructed by the private caregiver and hospice nurse. Based on interviews and record reviews, there is enough information to verify the allegation. Therefore, the 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 LIC 9099-D): No other health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued. During interviews, staff stated all staff have completed training and background clearances. Based on interviews and record reviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff did not follow reporting requirements. It was alleged that facility did not submit an incident report. To investigate the allegation, on April 1, 2026, the Department reviewed documents at around 11:00a.m. and interviewed one staff from 11:30a.m. – 12:00p.m. A review of the Department’s records revealed facility submitted a written report within seven (07) days of the occurrence. During interviews, staff stated the resident’s Responsible Party was at the facility within a few hours of the incident taking place. Based on interviews and record reviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No other health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued.