Complaint·March 2, 2023

The investigation revealed the following: Allegation - Neglect resulted in resident being physically assaulted by another resident causing significant injuries. IB investigator D. Douglas conducted interviews with the facility staff, doctors, and victim. During the investigation, it was revealed the Resident #1 (R-1) was not medication compliant prior to an initial incident that occurred on 10/1/21, which R-1 became agitated and was verbally abusive towards staff and other residents. R-1’s psychiatric doctor was notified and requested to send R-1 to the hospital for a psychiatric evaluation. R-1 was cleared to return to the facility after agreeing to comply with taking the psych medication. Upon returning from the hospital, R-1 was placed in another room with a roommate. Another incident took place on 11/6/21 in which R-1 physically assaulted the roommate (R-2). R-2 sustained injuries/lacerations to the hands and head. According to documentation gathered, R-1 was not compliant with medications after returning from the first incident. Staff indicated they tried to encourage R-1 to take the routine medications but could not force R-1 to take them. Some of the staff acknowledged the incidents and that R-1 was inconsistent with taking medication but stated that R-1 had not been physically or verbally abusive prior to the incidents. The Medication Administration Records (MAR) log showed that R-1 was inconsistently taking the psychosis medications from October 2022 – November 2022. Although the psychiatrist and primary physician were notified, the facility did not develop other plans to address R-1’s failure to comply with medications. There were no notes or updated needs and services plan provided to show that additional actions were taken after the first incident of aggressive behavior and the medication non-compliance. Therefore, the allegation of neglect resulting in physical assault of another client is substantiated. Based on interviews conducted and record review, 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. ***An immediate Civil Penalty of $500.00 is being issued today. Refer to LIC 421IM*** An exit interview was held. A copy of this report, LIC9099D, LIC421IM, and appeal rights were given to Administrator Lisa Pham.