complaint·June 29, 2025

In regard to the allegation “Resident's motorized wheelchair broke due to staff neglect”, It is alleged that S1 broke R1’s motorized wheelchair by turning it off and on. During interviews with Administrator, it was revealed that the wheelchair had never actually been broken and that the battery had just died. Three (3) out of three (3) staff all stated they have never witnessed staff break residents belongs. During interviews with residents’ thirteen (13) out of thirteen (13) stated that staff has never broken any of their belongs. R1 stated that S1 liked to turn their wheelchair off and on preventing it from working when the battery would die. Based on interviews conducted, and information that was gathered, there is insufficient evidence to support the allegation(s). Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. A copy of this report was given to the Administrator. In regard to the allegation “Resident was abandoned due to staff neglect”, It is alleged that S1 left R1 in an inoperable motorized wheelchair unable to call for assistance. During interviews with Administrator, it was revealed that S1 left R1 knowingly in wheelchair not working unable to reach for call button or phone to ask for assistance. It was also revealed that S1 admitted to Administrator to leaving R1 alone because of the behavior issues R1 displays. During interviews with residents twelve (12) out of thirteen (13) stated they have never been neglected by staff. R1 stated that S1 knew the chair was not working and did not assist them to bed leaving him/her sitting waiting for another caregiver to find them. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Administrator. A copy of the report and appeal rights were provided.