complaint·September 22, 2025

AW1 reported that R2 became agitated and responded with physical aggression towards R1. AW1 reported R1 yelled for staff assistance and called the facility number with no response, leading to calling law enforcement for assistance. Additionally, AW1 reported that the altercation resulted in injuries to R1 and medical transport for both residents. Interview with Executive Director, Valeria Garcia stated she was made aware of the incident and clarified that NOC staff are assigned to supervise the villas on a rotational basis. Executive Director stated the altercation occurred while staff were actively following protocol during their scheduled rounds. Valeria added that proper assessments, additional care plans, and staff monitoring have been adjusted for R2. Through interviews, 4 of 4 staff reported that they did not observe or hear of the altercation between R1 and R2. Additionally, they did not hear the facility phone ring and were made aware of the altercation when paramedics and law enforcement arrived at the facility. A review of facility records confirmed that the NOC shift operates from 10:00 PM to 6:00 AM and is staffed with three to four personnel responsible for the care of 54 residents. Through supplemental interviews, it was further corroborated that several residents remain active during these hours, often engaging in mobility throughout the facility. Additional information obtained indicated that frequent calls for assistance are common during NOC shift, which presents ongoing challenges in maintaining adequate supervision and ensuring consistent quality of care under the current staffing levels. Based on interviews and record reviews, the allegation that staff did not prevent a physical altercation between residents and staff did not respond to resident's calls for assistance is Substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The facility will be cited. An exit interview was conducted. A copy of this report was provided to Executive Director Valeria Garcia, and Administrator Liliana Moreno along with a copy of the LIC9099-C, LIC9099D, and Appeal Rights were provided.