complaint·May 8, 2025

It was alleged that, due to staff’s lack of care and supervision of residents in the memory care unit, on May 3, 2025, Resident #1 (R1) was attacked by R2, who has a history of aggressive behavior, resulting in a bruise. LPA inspected the facility, conducted health and safety checks on residents, including R1 and R2, noted that R1 has a small bruise on their cheek and that R1 has been relocated to another floor in the memory care unit, and observed no health and safety issues. LPA interviewed R1 and R2 who denied engaging in any fights or sustaining any injuries, stated they receive good care at the facility, and denied having any problems at the facility. LPA interviewed the facility’s medication technician supervisor who stated that on May 3, 2025, staff in the third-floor memory care heard a fall, observed R1’s door open with R1 on the floor inside and R2 standing outside the room, noted no serious injuries on R1, offered R1 first aid and reported the fall to R1’s doctor, but did not observe whether R1 fell or was pushed by R2. Per the facility’s medication technician supervisor, three caregivers are assigned to the third-floor memory care and the facility’s resident roster indicates there are 35 residents in the third-floor memory care. Interviews with staff confirmed that three caregivers were working on the third-floor memory care at the time of the incident. LPA interviewed three staff who were witnesses to the incident, and one confirmed seeing R2 push R1 causing R1’s fall. All four staff interviewed also confirmed that R2 has a history of aggression. LPA reviewed R2’s Physician’s Report dated January 1, 2025, which indicates R2 has Dementia, and R2’s Appraisal/Needs and Services Plan dated February 1, 2024, which was not updated as required due to R2’s Dementia diagnosis, does not indicate R2 has a history of aggressive behavior as confirmed by facility staff, or provide a care plan to address R2’s aggressive behavior. Interviews with three staff confirmed that the incident was caused when R2 was left to wander around the memory care, confirming that no special care was provided to address R2’s aggressive behavior. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.