complaint·February 18, 2026

Based on the bruising and statements made, S1 was arrested. A review of the police report dated 08-25-25 revealed R1 had an abrasion on right arm, which was about one inch in diameter and had blood on it. The report also states that R1 had a bruise on the left side of face on the cheek that was about one inch in diameter. It was reported that R1 had minor redness to the right side of the face near cheek and to the bridge of nose. S1 was interviewed and reported while assisting R1, R1 became resistant and dug their nails into S1. S1 then placed R1 on the bed to allow R1 time to calm down. S1 reported they attempted a second time to assist R1 and was again scratched. When S1 placed R1 back down on the bed, for a second time, their left accidentally made contact with R1’s face. S1 reported this was not intentional and occurred while repositioning the resident. It was alleged that staff mishandled a resident. Concerns were raised that S1 picked up R1 and threw them onto the bed. During the investigation, LPA conducted interviews with three staff members. All interviewed staff stated that while R1 can sometimes be challenging and exhibit aggressive behaviors such as scratching or kicking, they do not believe S1 mishandled R1. Staff described S1 as generally calm and professional when providing care. An interview with S1 revealed that they denied ever mishandling R1 and stated that they always treat residents with dignity and respect. S1 explained that on the day of the incident, they attempted to assist R1 in getting out of bed, but R1 resisted and scratched them. S1 reported that they placed R1 back on the bed to allow time to calm down before attempting again. Although staff interviews generally supported S1’s professionalism, the investigation determined that S1’s own admission of physically placing R1 back on the bed after resistance, combined with the allegation details, supports that inappropriate handling occurred. The action of picking up and placing R1 back on the bed, even if intended to calm the resident, constitutes mishandling under Title 22 because it involved physical force without proper de-escalation techniques. Based on record review and interviews, 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, and a copy of this report and the 9099-D was provided to Licensee Elizabeth Hengstler. An immediate civil penalty was assessed in the amount of $500