complaint·March 19, 2025

after they conducted a thorough investigation following S6's suspension as R1's integrity's at risk and for the concerns noted in accurate reporting on the reported 01/01/2024 incident at the facility. S1 provided LPA Brown copies of S6's Corrective Actions and their Incident Investigation. LPAs Brown and Gardner were able to obtain evidence to corroborate that S6 did not treat R1 with dignity or respect. The allegation staff did not treat resident with dignity or respect is found to be SUBSTANTIATED. A deficiency is being issued per California Code of Regulations (CCR), Title 22. A substantiated finding means that the allegation staff did not treat resident with dignity or respect is valid because the preponderance of evidence standard has been met. An exit interview was conducted where this report, LIC9099, LIC9099D, and Appeal Rights were discussed and provided to District Director of Clinical Services Sheryl Hendricks, RN, and ED Brittney Martinez, LVN. it cannot be conclusively established when and where R1’s injuries occurred and therefore cannot be shown that R1’s injuries were a result of staff neglect. Department staff interviews with other staffs cannot corroborate that S6 somehow failed to act or otherwise intervene during R1’s behaviors. Second allegation: Staff did not meet the needs of residents in care. The investigation was conducted by LPAs Melody Brown and Ryan Gardner which consisted of file review, observation and interviews with relevant parties. During the investigation, LPAs Brown and Gardner were not able to obtain sufficient evidence to support that staff did not meet the needs of residents in care. LPAs Brown and Gardner interviewed six (6) residents and six (6) of six (6) residents residents indicated that staffs at the facility are meeting their needs as they are providing care and supervision to them, checking on them multiple times in a day and they promptly assist them if needed. Interview with seven (7) of seven (7) staffs indicated that they are meeting the needs of the residents at the facility daily as they are checking on them every one (1) hour or every two (2) hours if they need assistance, to keep their incontinent residents clean and dry and to ensure the residents safety. Seven (7) of seven (7) staffs interviewed stated that they are provided monthly training to ensure that they are providing appropriate care and supervision to all their residents. During the facility visit on 12/05/2024, and 03/04/2025, LPA Brown observed staffs at the facility are checking on their residents and providing care and supervision. Third allegation: Staff illegally evicted resident. The investigation was conducted by LPAs Melody Brown and Ryan Gardner which consisted of records review and interviews with relevant parties. The third allegation indicates that staff illegally evicted resident. During the investigation, LPAs Brown and Gardner were not able to obtain sufficient evidence to corroborate the allegation. Interview with Staff #1 (S1) indicated that R1 was given 30 days Eviction Notice on 12/27/2023 as it has been determined that R1 has a need not previously identified that requires a higher level of care than what the facility can provide. During the facility visit on 12/05/2024, S1 provided LPA Brown a copy of 30-Day Notice and proof of delivery sent to R1 family/Responsible Person. Fourth allegation: Staff did not refund fees according to resident's Admission Agreement. The investigation was conducted by LPAs Melody Brown and Ryan Gardner which consisted of file review, observation and interviews with relevant parties. During the investigation, LPAs Brown and Gardner were not able to obtain sufficient evidence to support that staff did not refund fees ***Continuation in LIC9099C*** according to resident's Admission Agreement. Interview with Staff #1 (S1) indicated that R1's family/Responsible Person was refunded $1,200.00 which is 40% of the community fee as $500.00 of the Community Fee becomes non-refundable due to R1 completing the Pre-Admission Appraisal (Personal Service Assessment). Documents review indicated that community fee's $3,500.00 and LPA Brown noted that R1 has a completed Pre-Admission Appraisal (Personal Service Assessment) which makes the $500.00 non-refundable and 40% of the community fee less the $500.00 non-refundable is $1,200.00. Therefore, based on the evidence obtained during the Department staff, LPAs Brown and Gardner's investigation, there is insufficient evidence to prove that Resident #1 (R1) suffered a broken elbow and a torn rotator cuff during a behavior incident due to staff neglect (Allegation #1), staff did not meet the needs of residents in care (Allegation #2), staff illegally evicted resident (Allegation #3) and staff did not refund fees according to resident's Admission Agreement (Allegation #4) are UNSUBSTANTIATED at this time. Although the allegations of Resident #1 (R1) suffered a broken elbow and a torn rotator cuff during a behavior incident due to staff neglect (Allegation #1), staff did not meet the needs of residents in care (Allegation #2), staff illegally evicted resident (Allegation #3) and staff did not refund fees according to resident's Admission Agreement (Allegation #4) 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 at this time. An exit interview was conducted where this report (LIC9099), was discussed and provided to District Director of Clinical Services Sheryl Hendricks, RN, and ED Brittney Martinez, LVN.