complaint·June 7, 2025

The investigation revealed the following: regarding the allegation “Resident is being physically abused while in care.” It is alleged facility staff are abusing residents in the dementia wing of the facility. According to staff interviews conducted by LPA Ramirez, S1 was observed pushing resident R1 down into their bed, handled residents roughly during dressing and forcefully sat them down. Additionally, S1 was seen being dismissive and diminishing towards R1, saying “you’re not the princess”. Staff interviews did not reveal any residents were injured as a result of S1’s conduct. Record reviewed by LPA Ramirez did not reveal residents were injured as a result of S1’s conduct. Following an internal investigation, the facility terminated S1’s employment as of May 12, 2025. LPA Ramirez obtained a copy of Sierra Madre Police Incident Report dated 04/29/2025. This incident report did not corroborate this allegation. Interview with R1’s responsible party did not corroborate this allegation. Due to cognitive impairments, R1 was unable to provide a meaningful interview. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated . Per Title 22, Division 6, Chapter 8, Article 08 Resident Assessments, Fundamental Services and Right- 87468.1(a)(3)- Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. S1’s conduct poses an immediate threat to the physical health, mental health, or safety of residents in care. Therefore, LPA Ramirez will issue a Type A deficiency. One (1) deficiency was cited for this complaint investigation. A copy of this report, 9099-D, and appeals rights was provided.