complaint·February 18, 2026

9099C-1.. (R1’s) care plan (7/16/2025) states staff will ensure (R1) has safe ambulation, provide occasional assistance, they use a walker due to unsteady gait, and notes that (R1) "displays behavioral expressions such as agitation, refusal of care and confusion" and "requires reminders and cueing". Allegation: Staff hit resident. The allegation states that staff, (S1), physically punched resident (R1), in the back of their head around the end of August or beginning of September, 2025, and then went after (R1) attempting to punch (R1) more, but another staff intervened so (S1) walked away. LPA reviewed (5) staff statements and other documentation from the facility's internal investigation. (4) of the statements were from caregivers who were present at the start of the "am" shift on September 1, 2025, when the incident with (R1) occurred, and (1) statement was from the Med-Tech who received a verbal report from one of the caregivers later that same day, around 1:50 pm. LPA interviewed each of these (5) staff and was provided with varying accounts of how the incident occurred from the (4) staff who were witnesses. Although all caregivers stated that they observed (R1) pulled (S1's) hair, one caregiver stated they heard (S1) call (R1) "crazy", just prior to (R1) pulling (S1's) hair. Another caregiver who is familiar with (R1) stated they have observed (R1) to become aggressive with other residents, but never with a staff. Additionally, the written statements from the (4) caregivers do not include details or corroborate the information provided to the LPA during the interviews. One caregiver stated they provided details to management about what they witnessed; however, their written statement did not reflect a detailed account of the incident, and was not signed. LPA reviewed a second witness statement that also was not signed by the caregiver. The Med-Tech confirmed that what was reported to them by one caregiver was documented and submitted to management following the incident . In the Med-Tech's statement, it's also noted that (S1) was told they need to make a report of what was witnessed, as well as the (2) other caregivers who did not report what they witnessed. The facility's internal investigation "determined that the resident abuse claim was inconclusive; however, concerns about professional conduct and proper intervention were substantiated". As part of a corrective action plan, (S1) was issued a Performance Improvement Plan (PIP) on September 6, 2025, requiring (S1) to complete "mandatory training in de-escalation techniques, dementia care and customer service standards" with the purpose to “provide corrective direction, training and support to ensure safe, professional and compassionate care practices”. *cont on 9099C-2.. 9099C-2.. As part of the corrective action plan, (R1) was also required to review the facility's policies on Behavioral Intervention and Resident Rights, and participate in weekly 1:1 check-ins with a manager to discuss progress every (30) days. LPA reviewed documentation showing (R1) was evaluated on Oct 13, 2025, Dec 16, 2025, and on Jan 19, 2026. The Ombudsman met with the Administrator and the DON initially on November 18, 2025 and was told an internal investigation was completed and there was no evidence found to substantiate the allegation of abuse. The Ombudsman returned to the facility on November 19, 2025 to inform facility managers that (S1) was involved in a similar incident, that was witnessed at an unrelated facility, on November 14, 2025. During the meeting on November 19, 2025, it was discussed that a Report of Suspected Dependent Adult/Elder Abuse ( SOC341) should have submitted to the Long-Term Care Regional's Ombudsman's Office immediately following the reporting of the abuse. The facility submitted a completed incident report (LIC624) to the Department (CCLD) after this meeting. Charting notes for (R1) show on 9/1/25 (1:00 am) staff made an entry that (R1) was observed with an indentation and cut on their outer right side of temple and that (R1) did not fall, but bumped their head on the night stand next to the bed, and refused to be sent out. Interviews concluded that staff were aware and observed (R1) had sustained bruising to their eye during the prior/NOC shift. There were no notes entered by the Med-Tech for the altercation (R1) had with (S1) on 9/1/25 (around 6:15 am). The next notes were entered on 9/4/25 (1:52 pm) and 9/5/25 (1:16 pm) and state that resident’s eye bruises (black eye) are healing and going away, resident is not complaining of pain/discomfort, and staff will continue to monitor. Based on information obtained, the allegation is found to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (2) citations are issued on the 9099-D page. Exit interview. Copy of report and appeal rights provided.