complaint·November 26, 2024

During the investigation, interviews were conducted with S1, S2, S3, and other pertinent individuals. Investigation revealed that prior to injuries observed, R1 was at the facility. Interviews with S1, S2, S3 further support awareness of injuries and that the injuries were sustained at the facility. However, there were conflicting accounts provided by S2 and S3 as to how R1 sustained or could have sustained the injuries. In addition, S1 reported that S1 was not aware of the injuries until another party reported it to S1. Based upon a review of R1 records, services such as continuous care, supervision, and observation for changes in physical, mental, emotional, and social functioning was to be provided. In addition, services such as assistance with declining mobility and behavioral issues are also indicated as being provided to R1. However, the preponderance of evidence supports that facility staff failed to provide the identified care and supervision to R1 on or around February 10, 2020. As a result, R1 sustaining unexplained injuries. The above allegation is found to be SUBSTANTIATED. A deficiency is being issued per California Code of Regulations, Title 22. An exit interview was conducted where this report, LIC9099D, and appeal rights were discussed, and copies provided to the Administrator Destiny Villalta. However, the manner in which injuries were sustained could not be confirmed to have occurred as a result of physical abuse by staff. There were no witnesses identified who confirmed physical abuse. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to Administrator Destiny Villalta