Complaint·September 24, 2025

Interview with Resident 1 (R1) reported being attacked with an object in their room. R1 was unable to describe the object, provide the individual’s name, or offer a physical description, stating only that they did not recognize them. Later in the same interview, R1 recalled that the individual may have been in a wheelchair and had a woman’s name, though no further identifying details were provided. R1 stated that they did not press their emergency pendant or call out for staff assistance during the incident, explaining that they were focused on the pain and didn’t think to do so. Despite the alleged event, R1 expressed that they do not feel neglected by the facility staff and affirmed that they do a good job caring for her. Interview with Resident 2 (R2) stated that they entered R1’s room on August 23, 2025. R2 reported calling out to R1 and believed they heard a response granting permission to enter. As R2 moved closer, R1 appeared startled, disoriented, and confused. R2 denied any physical contact with R1 and stated that they exited the room shortly thereafter. R2 expressed that they had no reason to believe their actions would be interpreted as an assault. Interview with Witness 1 (W1) revealed that they did not hear an attack take place and could only acknowledge that R2 was at the entrance of the door. W1 could not determine if R2 entered the room since a covering separates their beds. W1 added that even though their view was obstructed, they did not hear any altercation or attack had occurred. Interview with Executive Director Molly Bowie (ED) reported that staff had not reported any concerns with observed interactions between R1 and R2. ED added that R1 waited until the following morning to report the alleged attack to staff. ED stated that proper procedure was followed, contacting law enforcement and responsible parties. ED stated that the allegation was handled with diligence and investigation did not result in valid concerns. Interview with 5 out 5 staff corroborated that R1 did not have any visual bruising or marks consistent with a physical attack. Additionally, it was supported that R2 is observed to be vocal with their words and not known to have a history of physical aggression towards staff or residents. Continued on LIC 9099-C. On August 29, 2025, Licensing Program Analyst (LPA) Armando Perez conducted observations related to the reported allegation. During the visual assessment of areas reviewed, no injuries or physical markings were observed on R1 that would be consistent with signs of a physical assault. Through record review of staff scheduling records indicated that adequate staffing levels were in place to support proper resident supervision. Additionally, it appears sufficient staff were available to respond to the emergency if R1 had utilized the call system. Based on interviews, record reviews and observations the allegation that a resident hit another resident due to staff neglect has been deemed UNSUBSTANTIATED. A finding that the allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted. A copy of this report was provided to Activities Director Olga Morales.