complaint·April 20, 2026

Allegation #1: Staff did not prevent resident from causing injuries to another resident in care. The complaint alleged that the resident was physically assaulted by another resident and sustained injuries to the resident's eyes. On April 16, 2026, the department interviewed the Executive Director (ED) and the Administrator (A1), both of whom stated that they try to have more staff around residents who are aggressive toward other residents. The Administrator noted that the caregivers are aware of which residents require more supervision and who are likely to act aggressively. Additionally, four staff members (S1-S4) were interviewed, all of whom denied the allegation. They also stated that they are very alert and proactive around residents to prevent any residents from causing injuries to others. The department then interviewed six residents (R3-R8). 6 out of the six residents denied ever being hurt by other residents. However, the department was unable to interview R1 and R2 because they no longer reside at the facility. On April 16, 2026, the department reviewed the facility's notes dated 09/06/24 through 09/13/24, which documented that the facility assigned a one-on-one caregiver to R1 due to aggressive behavior and altercations with others. On 09/11/24, during the incident, the caregiver intervened and called Medical Emergency Services (MES), which transported residents R1 and R2 to the hospital. R2 was placed on a 51/50 hold. Both were discharged on 09/12/24. The department also reviewed the Unusual Incident Report dated 09/12/24, which was sent to Community Care Licensing and the Ombudsman. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to Administrator Liliana Moreno.