complaint·October 3, 2025

CONTINUED FROM LIC9099 There is no indication of dementia or mild cognitive impairment on the medical assessment dated November 29, 2023. Upon admission, it was documented that R1 opted out of providing the facility with an inventory of personal property. R1’s records obtained at the facility additionally included multiple Physician’s Fax Report of Fall dated January 4, 2024, February 13, 2024, June 11, 2024, January 13, 2025, March 5, 2025, March 6, 2025. In each of those instances, the primary care provider was notified and followed up. Adequate calls to 911 for evaluation and either transportation to a hospital or refusal to pursue such evaluation were systematically documented as well, as confirmed by the charting notes obtained and reviewed. A Resident Notice to Vacate was provided by R1’s responsible party to the facility on April 5, 2025 informing the facility of R1’s intent to be discharged from the facility effective April 13, 2025. The motive stated on the notice is “ multiple theft of cash and property, right wrist fracture due to employee negligence and involvement in a fall without proper response time ”. R1 was therefore no longer a resident at the facility when the investigation was initiated. Regarding the allegation that Staff stole residents personal property , the following has been concluded: During the investigation, licensing staff reviewed video footage from a video device installed by R1’s family inside unit #151. Video reviewed shows staff member S1 going into R1’s bedroom closet and removing items. S1 then comes into view of the camera and appears to back away out of view, before proceeding to walk by with items in hand. S1 is later seen leaving R1’s residential unit with items in hand. According to staff interviews, S1 instructed another staff member to tell her later in the shift, in the presence of other staff, to enjoy the items they gave them (even though staff did not give S1 anything). Accomplice staff agreed, later telling S1 that they hopes they enjoys the items and S1 thanked him for the gifts that he gave her. There is enough evidence to support the allegation that S1 stole items from R1’s residential unit. CONTINUED ON FORM LIC9099-C CONTINUED FROM LIC9099-C Regarding the allegation that Staff did not respond to residents calls for assistance timely , it was determined that: During the investigation, licensing staff reviewed the Unusual Incident Report and interviewed the Med Tech that completed the report. Based on the report, R1 sustained a fall in the bathroom and pulled the emergency cord in the bathroom before crawling to their cell phone in the bedroom. R1 called their family who then called facility staff. R1’s family provided a time-stamped record of the calls confirming multiple phone calls to the facility were made. Once the call was received, the facility responded to provide aid/assistance. Both the report reviewed and a statement made by a staff member interviewed advised that the resident was not wearing her emergency pendant when staff responded. Additionally, there was construction occurring at the facility in which the emergency cords in the bathroom were being removed. As a result, the facility staff stated they had thought the residents’ emergency cord notification was a false alarm due to the ongoing construction. There is enough evidence to support the allegation that there was a delay in providing assistance to R1 in a timely manner. Based on the evidence gathered, the allegations that Staff stole residents personal property and that Staff did not respond to residents calls for assistance timely are both found to be Substantiated , meaning that the preponderance of evidence has been met. See LIC9099-D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM LIC9099-A There is no indication of dementia or mild cognitive impairment on the medical assessment dated November 29, 2023. Upon admission, it was documented that R1 opted out of providing the facility with an inventory of personal property. R1’s records obtained at the facility additionally included multiple Physician’s Fax Report of Fall dated January 4, 2024, February 13, 2024, June 11, 2024, January 13, 2025, March 5, 2025, March 6, 2025. In each of those instances, the primary care provider was notified and followed up. Adequate calls to 911 for evaluation and either transportation to a hospital or refusal to pursue such evaluation were systematically documented as well, as confirmed by the charting notes obtained and reviewed. A Resident Notice to Vacate was provided by R1’s responsible party to the facility on April 5, 2025 informing the facility of R1’s intent to be discharged from the facility effective April 13, 2025. The motive stated on the notice is “multiple theft of cash and property, right wrist fracture due to employee negligence and involvement in a fall without proper response time”. R1 was therefore no longer a resident at the facility when the investigation was initiated. Regarding the allegation that Staff did not seek timely medical care for resident , it was determined that: during the investigation, licensing staff reviewed the facility Charting Notes for R1 and also interviewed facility staff and R1’s family member. The Charting Notes document that R1 sustained an injury from a fall but also that R1 refused to accept treatment/transportation if 9-1-1 emergency personnel were called. R1 requested to be checked out for injury by a family member, who R1 stated is a doctor. Family member confirmed they are a physician and corroborated the account of refusal of medical treatment on the day of the fall incident. A few days later, R1 consented to hospital transportation. There is insufficient evidence to support the allegation of the facility failing to obtain medical attention. Regarding the allegation that Staff financially abused resident , the following has been concluded: During the investigation, licensing staff conducted interviews with facility staff, clients, victim, and witnesses. The interviews conducted provided insufficient corroborating information regarding the allegation of staff stealing/removing money from R1’s possessions or bedroom. More importantly, the information provided did not allow to identify any individual staff that may have had direct involvement in the theft of cash. There is therefore insufficient evidence to support the allegation of staff stealing money from the resident. CONTINUED ON FORM LIC9099-C CONTINUED FROM FORM LIC9099-C Regarding the allegation that Staff pushed resident causing injury , the following has been concluded: During the investigation, licensing staff conducted interviews with facility staff, clients, alleged victim, and witnesses. The interviews conducted provided insufficient corroborating information regarding the allegation of staff pushing or intentionally causing victim to fall. No specific alleged perpetrator was also identified based on the interviews. There is therefore insufficient evidence to support the allegation of staff intentionally pushing or causing the resident to sustain injury. Based on the evidence gathered, the allegations that Staff did not seek timely medical care for resident , Staff financially abused resident and that Staff pushed resident causing injury are found to be Unsubstantiated , meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.