Complaint·April 6, 2023

Per Resident Admission Agreement facility may terminate the Agreement “for one or more of the following reasons: Failure of the Resident to comply with the general policies of the Community as outlined in the Resident Handbook…” Per Unusual Incident/Injury Report (UIR) dated 01/13/23 it was reported Resident 1 (R1) was physically assaulted by R2. During another incident, it was reported via Suspected Dependent Adult/Elder Abuse (SOC341) dated 03/13/23 that R1 was again physically assaulted this time by R3. Per Facility’s Progress Notes for R1 dated 03/04/23 R1 was witnessed calling their roommate names and being verbally aggressive. Seven out of nine individuals interviewed reported that R1 can be problematic and verbally aggressive. On 03/14/23 facility issued a written eviction notice to R1 for verbal and physical altercations with other residents. The Department received a copy of the eviction notice on 03/14/23 and upon review determined it was not in alignment with regulatory requirements for Eviction Procedures as outlined in Tittle 22, Section 87224 Eviction Procedures because facility failed to properly document R1’s failure to comply with general policies of the facility. Although incident reports received note R1 was involved in multiple physical altercations at the facility, incident reports describe R1 as the victim, not the aggressor. Although R1 was observed engaging in verbal altercations, it remains unclear at this time if incidents surmount to a violation of the house rules. Regarding the allegation that resident was physically attacked by another resident due to lack of care and supervision, the investigation revealed the following: Per UIR dated 01/13/23 it was reported that R1 was physically assaulted by R2. During another incident, it was reported via SOC341 dated 03/13/23 that R1 was again physically assaulted this time by R3. The facility reported a total census of eighty-nine residents. LPA reviewed a total of five resident files. Four of five resident files reviewed indicate that residents are ambulatory and require minimum assistance with activities of daily living (ADLs). Records reviewed included the staff schedule. On average there are two caregivers and one medication technician in the morning shift (6a.m.-2p.m), one caregiver and one medication technician in the evening shift (2p.m.-10p.m.), and one caregiver and one medication technician in the night shift (10p.m.-6a.m.). Six of nine individuals interviewed reported that facility staff are helpful and/or that facility has enough staff to care for residents. The remaining three individuals reported that facility is understaffed. CONTINUED on LIC9099C... Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. LPA Ramirez conducted an exit interview with OM Aguirre, and a copy of this report was provided to the facility.