complaint·March 4, 2026

Collateral interview with witness (P1) stated that on 2/3/26 at around 5:25PM they overheard Staff 3 (S3) yell the word “stupid” “why would you do that?” “you’re stupid”, “its so stupid”. Resident 1 (R1) was observed to face away from them in the hallway and it appeared they were trying to wheel their wheelchair way from S3. P1 stated they did not observe whether or not S3 handled R1 in a rough manner. Staff 1 (S1) and Staff 2 (S2) stated the facility did an internal investigation was initiated immidiatley on 2/3/26 which included reviewing video footage and interviews. The facility determined that S3 did not physically handle R1 in a rough manner. However, S1 stated the encounter observed does not meet the facilities’ standards. P1 stated S3 did not “yell” but they sounded frustrated and called them "stupid louder than regular speaking voice. It was determined by the facility that S3 did not treat R1 with dignity and respect, S1 stated this was an isolated incident in which no other staff has been observed not treat a resident with dignity and respect. S1 also stated preventative measures were taken prior to this incident and immediate measures were taken after the incident on 2/3/26 to ensure staff are trained on re-direction and resident's personal rights. S1 stated all staff including S3 received two days of dementia specific training focusing in redirection for individuals with wondering behaviors. S3 was immediately placed on leave on 2/3/26 and the investigation concluded on 2/10/26, in which it was determined S3's employment would no longer return to the facility. LPA reviewed video footage in which it was observed, in which it was corroborated that S3 was redirecting the resident out of room 139 and into the hallway. They pushed R1 down the hallway and released the wheel chair handle bars behind R1 simultaneously in which R1 proceeded to continue to wheel themselves down the hallway away from S3. S3 then turned away from R1 and opened the exterior door, it was reported there was someone knocking on the door and video footage confirms that S3 let the individual knocking into the facility. Video footage confirms S3 then proceeds to walk towards another hallway away from R3 and did not return to assist R1. In response to this incident, the facility held a mandatory meeting for all staff was held on 2/5/26 by S1 regarding Personal rights, expectations, positive approach, re-direction. An additional service was held on 2/4/26 called "Treating Residents with Kindness, Respect, and Professionalism". S1 reported that S3 was terminated as of 2/10/26 and has been disassociated from the facility. Based on interviews and record review of the LPA and review of records the allegation Staff yelled at resident is substantiated. Based on interviews and record review of the LPA and review of records the allegation Staff does not treat resident with dignity and respect is substantiated. As a result, the allegations above are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted S1 and S2 and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility. Staff 1 (S1) and Staff 2 (S2) stated the facility did an internal investigation which included reviewing video footage and interviews. LPA observed through video footage that S3 was assisting R1 out of another residents room, however there is no audio in the video footage. There is not enough evidence that S1 yelled at R1, was not a preponderance of the evidence obtained to corroborate the allegation "Staff yelled at resident", however it was determined that S3 did not treat R1 with dignity and respect on 2/3/26. S1 stated this was an isolated incident in which no other staff has been observed not treat a resident with dignity and respect. S1 also stated preventative measures were taken prior to this incident and immediate measures were taken after the incident on 2/3/26 to ensure staff are trained on re-direction and resident's personal rights. Interview with witness (P1) stated that on 2/3/26 at around they overheard. Staff 3 (S3) yell the word “stupid” “why would you do that?” “you're stupid”, “its so stupid”. Resident 1 (R1) was observed to try to wheel their wheel chair way from S3. P1 stated S3 spoke to R1 in an volume higher than a regular speaking voice. The facility was unable to determined if S3 yelled at R1 as there was only one witness however it is determined the incident likely did occur In response, the facility held a mandatory meeting for all staff was held on 2/5/26 by S1 regarding Personal rights, expectations, positive approach, re-direction. An additional service was held on 2/4/26 called Treating Residents with Kindness, Respect, and Professionalism. The incident was reported to authorized representative, licensing (LPA, Kimberly Villarella), long term care ombudsman. An incident report and SOC 341 was completed. Based on interviews and record review of the allegation "Staff yelled at resident" is UNSUBSTANTIATED There are no deficiencies cited regarding this allegation per California Code Regulation, TITLE 22. Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility. Exit interview was conducted with the S1 and S2. Appeal Rights were issued, and a copy of this report was left at the facility.