complaint·August 13, 2025

6:30 am, June 23 6:30 am, June 19 7:00 am, June 18 5:30 am, June 17 5:30 am and June 15 6:30 am. 5 out of 5 staff interviewed reported that R1 gets up early and will start to get ready for the day by showering or shaving on their own. Staff reported that when they see R1 is awake they will assist. The Wellness Director reported that no one has reported that staff are waking up residents early in the morning to shower them or take their temperature. R1 moved out of the facility prior to the visit. None of the evidence gathered supports the allegation therefore the allegation is deemed unsubstantiated. 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. The investigation into the allegation, Staff yelled at resident, revealed the following. It was reported on June 23, 2021, staff yelled at R1. Witness (W1) reported that R1 called them and then forgot to hang up the phone and they heard a staff member yell at R1, “get out of bed, shut the hell up”. No other evidence was provided to support the allegation. Staff 1 (S1), Staff 2 (S2) and Staff 3 (S3) who were present at the facility on the night of June 23 denied the allegation. S1 and S2 reported they assessed R1 that night and reported no one was yelling at anyone that night. S3 reported they did not hear anyone yelling that night. Based on the evidence gathered the allegation is deemed unsubstantiated. 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. The investigation into the allegation Lack of supervision resulting in resident engaging in a physical altercation with another resident, revealed the following. It was reported that a female resident (name unknown) agitated R1 and then another resident, Resident 2 (R2) provoked R1. R1 then pushed R2 who fell on the ground. W1 reported that this was because there was a lack of supervision. A review of records shows that on July 8, 2021, 2 staff were present assisting the residents (8). R1 had their own care companion. On July 8, R1 told R2, “No you can’t come in here”. Then R1 pushed R2. R1’s care companion attempted to break R2’s fall but R2 still fell to the ground. Staff 4 (S4) and Staff 5 (S5) who were present redirected R1 and assisted R2. 911 was called and R2 was transported to the hospital but returned the same day with no new orders and no injuries. R1 has been diagnosed with Dementia and on their physician’s, report is noted to have aggressive and wandering behavior. R1 does have a private care companion and staff immediately acted to redirect R1 and to assist R2. S4 and S5 reported they are always checking on residents to ensure their safety and redirecting residents when necessary. The facility has done what it can to minimize the risk to all residents concerning aggressive behavior and has not displayed a lack of supervision regarding this allegation. Based on the evidence gathered the allegation is deemed unsubstantiated. 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. The entire lobby including the See Something, Say Something Poster (PUB 475) is visible from the main facility hallway. Based on the evidence gathered the allegation is deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The investigation into the allegation, Staff did not notify authorized representative of residents medical/medication changes, revealed the following. It was reported that the authorized representative/Responsible Party (RP) was not notified of any medical or medication changes. A review of R1’s records show that R1 did not undergo a change of condition while they were at the facility. R1 was prescribed 4 routine medications, Losartan, Omega 3, Vitamin D3 and Quetiapine. Vitamin D3 was added at R1’s RP’s request. Seroquel was changed to a PRN at the request of the RP. No other changes were noted in R1’s records. No specific details were provided as to what the RP was not notified of except for medical/medication changes. The medication changes were prompted by the RP and there were no medical changes reported. The facility did not have any medical or medication changes to report to the RP. Based on the evidence gathered the allegation deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of the report provided. Local Law Enforcement arrived and transported R1 back to the facility around 9:30 pm and staff assessed R1 and no injuries were noted. S1 and S2 verified this report. The ED reported that the staff have been trained on proper elopement protocol and proper supervision to verify the location of all residents to prevent elopement. According to R1's physician report they are not allowed to leave the facility unassisted. Based on the evidence gathered the preponderance of evidence standard has been met therefore the allegation is substantiated. Citation is being cited per Title 22, division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of the report along with the citation and appeal rights was provided to the facility representative.