complaint·January 18, 2026

Allegation: Resident was physically abuse while in care. The details of the complaint alleged that (R#1) was physically attacked by (R#2). On January 18, 2026, during a comprehensive records review, the department examined facility progress notes for (R#1) dated 9/25/24. The department observed that on 9/25/24, the day of the alleged abuse, facility staff found (R#1) face down on the floor without underwear and appearing to be under the influence. Staff noticed blood on (R#1) but could not locate the source, as no open wounds were visible. Due to (R#1)’s condition at the time, staff could not conduct a proper assessment. They promptly called emergency services, and (R#1) was transported to the emergency room. The progress notes contained no documentation indicating that (R#1) reported being physically attacked by (R#2). Moreover, the department observed (R#1)’s Physicians Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602A, dated 2/27/25. Under the physical health status, it is noted that (R#1) has mild cognitive impairment and uses alcohol. On January 17, 2026, at approximately 10:30 AM, the department interviewed (A#1), who provided his statement regarding the allegation. He stated that when the facility became aware of the alleged physical assault on September 29, 2024, staff immediately moved (R#1) to a different room and initiated an internal investigation. The investigation concluded that (R#2) did not physically abuse (R#1). There were no reports from any facility staff indicating they heard or observed an altercation between (R#1) and (R#2) at the time of the incident. Following the allegation, the facility interviewed (R#2) and determined there was insufficient evidence to substantiate the claim. The facility reported implementing measures to ensure resident safety during the investigation process. On January 17, 2026, at approximately 11:00 AM, the department interviewed (R#1), who stated that their interaction with their former roommate (R#2) was minimal, as they were simply roommates. When asked if (R#2) had ever physically abused them, (R#1) responded that (R#2) did not touch them at all. Evaluation Report continues LIC 9099-C On January 17, 2026, at approximately 2:00 PM, the department interviewed facility staff (S#1–S#4), (4) out of (4) stated that the facility monitors interactions between residents by redirecting them in ways that prevent conflicts. Staff reported that if they observe or hear a disagreement or altercation between residents, they intervene immediately and separate the individuals involved. In addition, (4) out of (4) facility staff stated that when asked if they were aware of (R#2) physically attacking (R#1), they had not seen that occur. Allegation: Lack of supervision resulted in the resident sustaining an injury The details of the complaint alleged that due to insufficient staff supervision, (R#1) sustained an injury. On 1/18/2026, during a comprehensive records review, the department examined the copy of (R#1)’s assessment tool dated:12/28/23, the department noted that it is written to support and mitigate (R#1)’s fall risk, caregivers should implement several interventions like closely monitoring their alcohol consumption and encourage them to participate in alcohol-free activities, check on them regularly especially the times when they are more likely to drink and provide companionship to reduce their isolation. In addition, ensure their living space is free of hazards that could contribute to falls, and consider arranging for a physical therapist to work on balance and strength exercises. In addition, the department examined facility progress notes for (R#1) dated 9/25/24; the progress notes contained no documentation indicating that (R#1) reported being physically attacked by (R#2). On January 17, 2026, at approximately 10:30 AM, the department interviewed (A#1), who stated that on September 29 and 30, 2024, since (R#1) and (R#2) were roommates and (R#1) uses alcohol, staff were checking on both residents every hour and as needed. Regarding the facility’s policy for preventing resident-to-resident altercations, (A#1) explained that the facility addresses complaints that may arise and, if necessary, separates residents who share a room. In addition, when asked if staff were aware of any prior conflicts or behavioral concerns involving (R#1) or other residents, (A#1) stated there was no documentation from facility staff witnessing any altercation between (R#1) and (R#2). Evaluation Report continues LIC 9099-C On January 17, 2026, at approximately 11:00 AM, the department interviewed residents (R#1–R#9), (9) out of (9) stated that they receive the help they need from staff and described staff as very helpful and they reported that there are enough staff available when assistance is needed and expressed that they feel safe living in the facility. On January 17, 2026, at approximately 12:00 PM, the department interviewed facility staff (S#1–S#4), (4) out of (4) stated that the facility ensures residents are adequately supervised throughout the day by observing them and listening to their concerns. In addition, (4) out of (4) facility staff stated that when asked whether they feel the residents are safe living in the facility, they responded that they do. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. 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, and a copy of the Complaint Report was given to Aurelien Fruit/Facility Administrator.