complaint·October 28, 2025

hairline. A police report obtained by the Department included a witness statement describing that upon touching the bruised area of R1’s shoulder, distinct welts could be felt. The witness indicated that the bruising pattern appeared consistent with the shape of a hand, suggesting that R1’s shoulder may have been forcefully grabbed or yanked. The photographs and police report collectively demonstrate the presence of extensive and severe bruising that, based on its visibility, should reasonably have been observed earlier in the day. Accordingly, medical evaluation should have been sought immediately upon discovery. Interviews conducted by LPA Tea with current facility staff, former staff members, and witnesses revealed that six out of nine interviewees confirmed the bruising was ultimately identified by R1’s daughter in the evening, prompting the facility to seek medical attention at that time. One staff member reported that earlier that morning, a caregiver had informed a medtech about the bruising; however, the information was not relayed to facility management. Another staff member stated that while they had noticed the lighter facial bruising, they were unaware of the more severe bruising on R1’s body. That staff member further confirmed that the facial bruising had been reported to management. Despite these internal reports, there is no evidence indicating that timely medical attention was sought by facility staff prior to the discovery by R1’s daughter later that evening. It was not until R1’s daughter’s discovery of their bruising that R1 was transported to the hospital emergency department for evaluation. A witness confirmed that diagnostic imaging, including a CT scan and blood work, revealed no fractures or internal bleeding and serious or severe injuries. Therefore, based on LPA Tea's observations, interviews conducted, and documents obtained, the allegation mentioned above has been determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted with Executive Director (ED) John Goodwin and Health & Wellness Director (HWD) Suzette Paige and a copy of this report and appeal rights were provided to the facility.