complaint·September 30, 2025

Investigation revealed the following: Allegation: Staff restrained resident. The detail of the complaint alleges that "Witness #1 (W1) made an unannounced visit to this facility on 2 different occasions and witnessed a resident restrained.” On 9/16/25 at 11:00am, the Department interviewed the Administrator (A1) regarding the above allegation. A1 denied the allegation, stating that he was not the Administrator during the time of incident but pointed out that there was a doctor’s order for a wheelchair restraint for R1. On 9/16/25, between 9:00am and 11:00am, the Department interviewed 2 staff regarding the above allegation, and of those interviewed 1 out of 2 were hired after the alleged incident occurred. 1 out of 2 stated that she was at the facility during that time and stated that there was a doctor’s order in place for a wheelchair restraint. However, 1 of the 2 staff interviewed admitted to using a “handmade” restraint to keep R1 from falling out of her wheelchair. Both staff stated that they are aware of the residents’ rights and know that a resident should not be restrained unless there is a doctor’s order such as a wheelchair restraint for safety. On 9/16/25, between 9:00 and 11:30am The Department interviewed 3 residents (R2-R4) regarding the above allegation. Of those interviewed 3 out of 3 stated that they have never been restrained at any time, stated that their rights are respected and they feel safe at the facility. Page 2 of 3 On 9/16/25, The Department obtained, reviewed and evaluated the following pertinent documents: Staff training: Resident Rights (dated 1/18/19) and Physician’s Order for R1’s wheelchair restraint (dated 7/13/22 and signed by doctor on 7/14/22, which indicates a request for wheelchair safety seat restraint to prevent from fall/injury was granted. On 9/23/25, the Department obtained via email and reviewed copy of R1’s incident/death report (dated 12/20/23). Based on LPAs interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) is being cited on the attached LIC 9099D. Exit interview conducted and copy of report and appeals rights provided.