Complaint·August 12, 2025

There was no direct observation, forensic evidence (like a medical report of an injury consistent with abuse), or other witness statements to support the claim that the injury was intentionally caused. Therefore, based on the evidence gathered during the investigation, the allegations listed above is deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Third Allegation : Staff threatened a resident while in care. The allegation of staff threatened resident 1 (R1) is found to be Unsubstantiated. While the resident made verbal statements alleging that R1 was “threatened” by a caregiver, there were no direct witnesses to the alleged staff threatening R1. Due to the victim’s diagnosis R1 was unable to recall the incident or provide accurate information in a consistent manner. Based on the evidence, there is insufficient evidence to prove that staff willingly threatened R1. Therefore, the finding is found to be unsubstantiated , it means there isn't enough evidence to confirm that the allegation occurred. Based on the evidence gathered during the investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report (LIC9099), LIC 9099C was discussed and provided to Facility Executive Director Griselda 'Gracie' Garcia. This incident occurred while the resident was being assisted by a staff member without the required Hoyer lift or the assistance of a second staff person, directly violating the resident's documented care plan. This failure to follow established protocols resulted in a preventable injury to R1. Based on observations, interviews, record reviews, and the totality of evidence gathered, there is sufficient evidence to support the allegation. The preponderance of evidence standard has been met, leading to the substantiated finding of Neglect/Lack of Care & Supervision. An exit interview was conducted, and this report (LIC809) LIC 809C, LIC809D and Appeal Rights were discussed and provided to Facility Executive Director Griselda Gracie Garcia.