complaint·April 7, 2026

R1s admissions agreement 5/8/2025, pre-placement, face-sheet, emergency information, physicians report & needs and service plan dated 5/8/2025 by email on 9/10/2025. At 2:30PM LPA conducted a tour of the facility which consisted of the dining and kitchen area and nine (9) residents’ bedrooms 56,65,57,59,55,18,20, 25, and 16. The investigation revealed the following: Allegation 2: Staff inappropriately spoke to resident. On September 9, 2025, Licensing Program Analyst (LPA) conducted interviews with Residents 1- 11 (R1–R11). Resident 1 (R1) reported that Staff inappropriately spoke to them about matters that were unrelated to their care . Resident 2 (R2) stated that they also heard S1 speaking to R 1 inappropriately by making inappropriate comments that were unrelated to caregiving. Residents 3-11 (R3–R11) reported that they had not experienced being spoken to inappropriately by any staff members. On 12/10/2025, LPA attempted to interview Staff 1 (S1); however, S1 was unavailable during the investigation and did not respond to phone contact made. Staff 2 (S2) and Staff 3 (S3) reported that S1 admitted to speaking to Resident 1 (R1) inappropriately while providing care on 9/1/2025. They stated they were aware of the allegation and that an internal investigation had been initiated. During this investigation, S1 was placed on probation and later terminated for violating company policy and failing to complete the introductory period. Staff members S4, S5, S6 and S7 stated that they did not personally witness or hear S1 speaking inappropriately to R1, but they were aware of the incident through other sources. Continued....... On 9/9/2025, LPA reviewed email correspondence sent to S1 on 9/4/2025 and S1’s personnel file that Included a notice of suspension and notice of separation form dated 9/9/2025 which reflected that S1 failed to complete their introductory period of employment and violated company policy. The LIC624 received stated that the resident in care was inappropriately spoken to on 9/1/2025 and SOC341 which was self reported to Ombudsman. Based on interviews conducted and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Continued ....