Complaint·April 30, 2026

Allegation: Staff did not seek medical attention for resident in a timely manner. The complaint alleges that residents (R1 & R2) engaged in a physical fight that resulted in injuries in both residents that required medical attention i.e. 1st Aid care and the residents did not receive any care because there were no AM med-techs on duty on Sunday April 26, 2026. The alleged incident occurred between 6:30 AM- 7:00 AM. NOC shift med-techs are off at 6:00 AM. A total of 14 residents were interviewed. Residents stated staff typically evaluate and provide care on site if there are minor injuries, and residents are sent out for medical attention if needed. Both residents (R1 & R2) confirmed they sustained injuries that resulted in bleeding. Resident (R1) was injured in the right eyebrow area and R2 had face injuries near the upper lip and right arm area. Staff interviews revealed that there were no med-techs working the morning shift on 4/26/2026. Therefore, residents (R1 & R2) did not receive 1st Aid medical attention at the facility. When residents have minor abrasions or minor open wounds med-techs apply saline solution, A & D ointment, and bandage the affected area(s). However, since all of the med-techs scheduled that day did not show up to work, and the facility currently does not have a Wellness Director that would have evaluated resident (R1 & R2's) injuries, neither resident receive 1st Aid care and/or medical attention in a timely manner. The Administrator and Assistant Administrator arrived at the facility several hours later because there were no med-techs working the morning shift. The residents did not receive timely 1st Aid care for their injuries. Based on record review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Pursuant to Title 22, California Code of Regulations, a deficiency was cited. An exit interview conducted with Assistant Administrator Alisa Dean. Due to printing issues the report was emailed. Allegation: Staff do not provide a safe environment for residents in care. It is alleged that on Sunday April 26, 2026, resident (R1) "slugged" resident (R2) causing a laceration in the eyebrow, lip, and arm. The complaint alleges staff are aware of resident behaviors that pose a risk to residents in care but the aggressive incidents are not addressed. According to information obtained, R1 has frequent aggressive behaviors towards other residents that lead to confrontations. It was also reported that there is a male resident that enters without consent the rooms of "vulnerable" females. A total 14 residents were interviewed. 11 out of 14 stated they feel safe, but acknowledged there are some residents that have aggressive behaviors due to mental disabilities. Residents confirmed the altercation/fight. Residents did not report knowledge of an alleged male entering female rooms. The alleged male was interviewed and stated they are invited into the rooms. A total of 9 staff were interviewed. The majority of staff stated the facility is safe. Interviews revealed that the resident altercation occurred between 6:30 AM- 7:00 AM, in the hallway outside the dining room. Resident (R1) hit R2's wheelchair and leg, and punched R2 in the face. Resident (R2) defended themselves and punched R1 back. Both residents sustained minor injuries that resulted in lacerations that bled. Kitchen staff notified staff via walkie-talkie of the incident. Resident (R2) called police later because staff did not notify law enforcement. Staff stated they did not call the police because R2 had already called the police. Due to insufficient information, the allegation cannot be supported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Exit interview conducted with Assistant Administrator Alisa Dean. Due to printing issues the report was emailed.