complaint·March 17, 2026

Staff interviews revealed that on the night of the incident, there were only two staff working. According to staff and Administrator interviews, there should have been three staff on NOC shift. According to the October staffing schedule, the NOC shift schedule was not consistently staffed with 3 employees. Per the Administrator, a full-time NOC shift employee had recently reduced their hours due to personal reasons. Interviews described R1 as having a tendency of wandering exit seeking behavior, and aggression towards staff and other residents. Although there was no previous incident of physical attacks from R1 to other residents, staff noted it was only a matter of time that R1 attacked a resident due to their aggression. According to R1’s needs and services plan, they required total assistance with interventions due to agitation and aggressiveness to ensure the safety of other residents. Additionally, R1 was identified as frequently exit seeking. R1’s physicians report lists R1’s primary diagnosis as Dementia with agitation and aggressive behaviors. Due to the facility’s inadequate staffing, staff on site could not properly supervise the residents which resulted in an altercation between two residents. Based on interviews conducted and documentation obtained, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiency is being cited on the attached 9099-D page. As a result of the resident's serious bodily injury, an immediate civil penalty per Health and Safety Code § 1548 in the amount of $500 is being assessed for a violation that the Department determines resulted in the injury or illness of a person in care. An additional civil penalty assessment is under review and determination is pending. LPA will return on a future date to assess an additional civil penalty if warranted. See 9099-D for citation Exit interview conducted. A copy of the report and appeal rights provided.