complaint·September 14, 2022

AD identified Staff #1 (S1) as the staff who had tied R1. In interviews, S1 stated that earlier that morning R1 had fallen from their wheelchair, that R1 kept trying to stand but was not able to stand or walk, so S1 used a scarf to secure R1 to their wheelchair for R1’s safety because the wheelchair did not have a seatbelt and R1 did not know that it was improper to tie residents to wheelchairs. S1 stated that they now know not to do it again. AD stated that shortly after the incident they trained staff to never to tie residents to their wheelchairs and to report any such incidents. On 09/14/22, LPA conducted a health and safety check on R1 and observed R1 to be in good health and good spirits. 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. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. AD stated that the staff conducting the activity arrived within minutes of AD arriving to the activity room. While the residents may have been left alone in the activity room, they were only left alone for a few minutes and staff were going back and forth to the activity room bringing residents to the activity and the staff conducting the activity arrived shortly thereafter. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.