complaint·April 15, 2026

Continued from LIC9099 Review of R1’s file showed that they moved to the facility with R2 in December 2025. The following entries were observed in R1’s progress notes: 12/27/2025: R2 voiced safety concerns about R1, stating that R1 has been showing abnormal behaviors such as being very angry and having verbal arguments with them. R2 expressed concerns that R1 could escalate the arguments physically. Per progress note, facility staff reached out to R1’s physician and R2 was instructed to press their pendant if they feel unsafe, to leave the room and find the nearest staff member. 01/04/2026: R1 became agitated and elbowed R2. R2 pressed their pendant and facility staff observed R1 threatening and attempting to grab the pendant out of R2’s hands in an attempt to prevent them from calling for help. R1 pushed R2 down on the bed. Facility staff intervened and were instructed to call emergency services if the situation escalated. Progress note also stated that an hour later R1 seemed confused. 01/05/2026: Facility staff, R1 and their POA held a meeting to discuss R1’s behaviors towards R2. Per notes, R1 was informed that they need to have another medical assessment and that aggressive behavior would be reported. Notes also stated that R1’s physician had been contacted multiple times. 01/20/2026: R1 was on alert charting for aggressive behavior and high blood pressure. Per interview with Health Services Director, alert charting is done for any unusual incident or change of condition for residents and is usually done for at least 72 hours or until the situation has been resolved. 01/24/2026: R1 had a phone call with their physician to address concerns related to their aggressive behavior and other medical concerns. R1’s Individualized Service Assessment dated 09/24/2025 stated that R1 did not have any behaviors that required staff intervention. R1’s Assisted Living Assessment dated 01/13/2026, stated that R1 did not have any behaviors that require staff intervention. Continued on LIC9099C Continued from LIC9099C Interview conducted with Health Services Director revealed that R1 and R2 have not received an updated care plan since 01/13/2026. Per interview, R1 and R2 have not been placed on frequent checks due to being very independent and are checked by facility staff at the beginning and end of each shift. Per Health Services Director, frequent checks would be done either every hour or every half hour if implemented. Interview further revealed that R1 and R2 do not have a one-on-one for supervision and that R2 has been instructed to call for help by pressing their pendant in the event they feel unsafe with R1. Per interview, facility staff try to respond to pendant calls in 10 minutes or less. Based on record review, interviews conducted, and observations made, this allegation is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.