complaint·January 7, 2026

Investigation Revealed the Following: Allegation: Staff are not providing adequate supervision resulting in residents sustaining bruises. The details of the complaint alleged that (R#1) sustained bruising because of the lack of supervision by facility staff. On 10/24/2025, during a comprehensive records review, Licensing Program Analyst (LPA) Alfonso Iniguez examined (R#1)’s hospitalization records dated 10/16/2025. The review focused on identifying any documentation that might indicate neglect or inadequate care by the assisted living facility. Upon careful examination, LPA observed that the medical records contained no written statements, physician notes, or diagnostic comments suggesting that (R#1) suffered negligence or harm attributable to their place of residence. The records primarily addressed (R#1)’s medical condition and treatment during hospitalization, with no reference to facility-related concerns. In addition, LPA Iniguez reviewed (R#1)’s Physician’s Report for Residential Care Facilities for the Elderly (LIC 602A) dated 05/20/2025. LPA noted that (R#1)’s documented mental condition may have contributed to their behavior and line of thinking, which could explain certain actions or resistance observed during care. On 10/23/2025, at approximately 3:30 PM, LPA Iniguez spoke with (W#1). (W#1) confirmed that the facility has contacted them whenever an incident involving (R#1) occurred. (W#1) stated they have not observed facility staff handling (R#1) in a rough manner. Additionally, during visits to (R#1), (W#1) observed that facility staff were present and assisting (R#1) appropriately. Furthermore, (W#1) explained that (R#1) bruises easily because she resists being changed by facility staff. (W#1) indicated this resistance is related to a cultural aspect, as (R#1) does not want to be seen nude by strangers. When such situations occur, (R#1) reportedly pulls herself forcefully, which may contribute to the bruising. Evaluation Report continues LIC 9099-C On 10/23/2025 at approximately 1:30 PM, LPA Iniguez interviewed (A#1) regarding (R#1)’s care and incidents at the facility. (A#1) stated the facility cannot provide incident reports or progress notes documenting when and how the bruises occurred on (R#1) because the bruises are unknown to them. (A#1) reported that body checks and skin assessments are conducted every time (R#1) is showered, and caregivers are responsible for observing any physical changes. Fall prevention measures currently in place for (R#1) include monitoring every two hours by care staff, a fall mat, and grab bars in the bathroom. (A#1) confirmed that (R#1) had a recent fall risk assessment due to previous falls. The facility’s protocol for notifying (R#1)’s family of injuries, behavioral incidents, or falls requires the MedTech or a licensed nurse to contact the family. (A#1) stated the facility has in-house notes documenting communication with (R#1)’s family regarding recent incidents. Additionally, (A#1) acknowledged language and cognitive barriers that affect communication with (R#1) and their representatives. (R#1) is checked by facility staff every two hours. On 10/23/2025 at approximately 2:30 PM, Licensing Program Analyst (LPA) Alfonso Iniguez attempted to interview (R#1). However, LPA was unable to speak with (R#1) due to cognitive impairment and language barriers. On 10/23/25 at approximately 3:00 PM, during interviews with facility residents (R#2-R#6), (5) out of (5) stated that they have ever noticed bruises or injuries on any resident including (R#1) and they feel there are enough facility staff to assist them when they need it. in addition, (5) out of (5) residents in care stated that they have never observed staff handling residents roughly or in a way that seemed inappropriate. Evaluation Report continues LIC 9099-C On 10/26/25 at approximately 2:00 PM, during interviews with facility staff (S#1-S#4), (4) out of (4) stated that body checks are routinely performed during personal care activities, such as showers and dressing. If bruising or any change in skin condition is observed on a resident (including R#1), staff document the observation in the resident’s progress notes, noting the date, time, location of the bruising, and any relevant context. Staff also stated they notify the nurse or MedTech and, when indicated, complete an incident report. Also, when asked about procedures for residents who resist care, staff explained that they use de-escalation techniques, including speaking softly, explaining each step of the process, and offering alternatives, such as assigning a different caregiver or rescheduling care for a later time. Staff emphasized maintaining resident privacy and modesty to reduce resistance. For R#1, staff follow care plan strategies designed to minimize agitation and reduce the risk of bruising. Resistant episodes and interventions used are documented in the resident’s record. In addition, (4) out of (4) facility staff stated that when asked if they had ever observed other staff handling residents, including (R#1), roughly or in an inappropriate manner, all four staff members stated they had not observed any such behavior. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Joel Niblett/Administrator.