Complaint·May 22, 2025

CONTINUED FROM FORM LIC9099-A During the follow-up to the investigation, LPA was provided with a recording of all activity related to pendant pushes for the period of December 23, 2024 until January 22, 2025. Staff records for staff member S1 were also provided during the March 18, 2025 visit and added to the investigation file. Regarding the allegation that Staff handle residents in a rough manner , the following has been concluded: Complaints of inappropriate staff interactions made during staff and resident interviews mostly described verbal interactions on behalf of staff member S1 rather than inappropriate or rough direct physical handling. No specific instances of rough handling were evidenced during the investigation. No specific acts were described by interviewees either during the present investigation. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided. CONTINUED FROM FORM LIC9099 During the follow-up to the investigation, LPA was provided with a recording of all activity related to pendant pushes for the period of December 23, 2024 until January 22, 2025. Staff records for staff member S1 were also provided during the March 18, 2025 visit and added to the investigation file. Regarding the allegation that Staff does not ensure residents are spoken to in an appropriate manner , the following has been concluded: Multiple staff members interviewed during the investigation related incidents they witnessed and/or reported to their supervisor involving inappropriate behavior from facility staff S1. Incidents described included ignoring calls for assistance, being short with residents requesting assistance, throwing medication across a table. Per a review of S1 staff files and interviews conducted, S1 was hired at the facility in 2011 and was terminated prior to the March 18 visit taking place due to inappropriate behavior. Regarding the allegation that Staff does not respond to call signal system for residents in a timely manner , the following has been concluded: Based on resident interviews and a review of pendant pushes over a period of 30-days, it was established that approximately three daily occurrences of pendant pushes requiring upwards of forty-five minutes to be addressed were recorded. While a wide majority of pendant pushes are addressed timely, these occurrences demonstrate that timely response is not guaranteed. As a result, both allegations are found to be Substantiated, meaning that the preponderance of evidence standard has been met. Two type B deficiencies are being cited per California Code of Regulations Title 22. An exit interview was conducted and a copy of this report and appeal rights were provided.