complaint·August 28, 2025

The Investigation Revealed the Following: Allegation: Facility staff caused injuries to resident during a transfer. It is alleged that R1 sustained injuries to their head during a transfer using a Hoyer Lift, that was assisted by S2 and S3. LPA conducted interviews with staff and 3 out of 6 staff confirmed the above allegation. S2 and S3 both confirmed the above allegation and stated that when they were using the hoyer lift, it was giving them trouble, the wheels got stuck and R1 landed on their bed from the hoyer lift. Part of the hoyer lift, grazed R1's forehead and R1 landed on her pillow, moments later blood was observed on the pillow and it was seen that R1 had an injury to the back of their head, 911 was called immediately. LPA reviewed in-service training for staff on usage of hoyer lift and it was explained to LPA by S1 that there is no documentation or proof that training prior to this incident was held. Since incident there have been 2 in-service training's dated 11/27/2024 and 12/4/2024, during staff interviews it was revealed that S6 has not received training for the hoyer lift and use the hoyer lift to assist residents with transfers. LPA interviewed residents and 8 out of 10 residents denied the allegation and stated they have never sustained injuries while being assisted nor have the witnessed/heard of any other resident sustaining an injury while being provided assistance/transfer. 2 of the 10 residents interviewed have a cognitive impairment that did not allow for successful interview. Based on observations and interviews which were 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 1 are being cited on the attached LIC 9099D. Immediate Civil Penalties were issued on 12/28/24, in the amount of $500.00 due to Staff caused serious injury to resident. At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(f) and may be assessed at a later date. Exit interview held and a copy of this report, appeal rights and civil penalty assessment were provided to Adriane Runge - Executive Director.