Complaint·December 31, 2025

R2 and R3 both denied that staff had ever poured or thrown water on residents. R3 she said they receive bed baths and that the water may sometimes feel cold but stated that staff have never intentionally thrown water on them. The facility administrator denied the allegation and reported no concerns related to staff throwing water on residents. The Sutter PACE nurse and medical social worker both reported that they were not aware of any such incidents and had not observed any concerns during their regular visits. RPP1 reported that R1 had previously stated that someone had been rough with R1; however, RPP1 also acknowledged that R1 experiences delusions, embellishes events, and has cognitive impairment, and RPP1 did not personally witness any incident involving water and has never physically been in the facility. A review of facility records did not identify any documentation of incidents, injuries, complaints or reports related to staff throwing water on residents. Based on these interviews and records reviews there is no corroboration of this allegation. The statements obtained do not support that staff threw water on a resident. The preponderance of evidence standard is not met for this allegation. Therefore, the above allegation is found to be UNSUBSTANTIATED. Allegation TWO: Staff slapped resident Interviews were conducted with the alleged victim (R1), two additional residents (R2 and R3), the facility administrator, a Sutter PACE nurse, a Sutter PACE medical social worker, and the responsible party (RPP1). R1 did not recall that any staff member slapped them and responded with uncertainty (“I don’t know” or “I wish I knew”) when asked about physical harm. R2 and R3 both denied that any staff member had ever hit, slapped, or physically harmed residents. R3 specifically stated that no staff member had ever hurt them at the facility. The facility administrator denied the allegation and reported no concerns of physical abuse. The Sutter PACE nurse and medical social worker, both of whom have regular contact with the resident and the facility, stated that they were not aware of any physical abuse and did not believe the allegation occurred. Continued on 9099C RPP1 reported that R1 had stated that a caregiver was rough with R1; however, RPP1 also acknowledged that R1 experiences delusions, occasionally embellishes events, and has cognitive impairment. RPP1 did not personally witness any incident of physical abuse. A review of facility records did not identify any documentation of injuries or incident reports. Based on the interviews, there is no corroboration of the allegation, and the information obtained does not support a finding, by a preponderance of the evidence, that staff slapped a resident. The preponderance of evidence standard is not met for this allegation. Therefore, the above allegation is found to be UNSUBSTANTIATED. Allegation THREE: Due to lack of supervision, an adult went into residents’ room Interviews were conducted with the alleged victim (R1), two additional residents (R2 and R3), the facility administrator, a Sutter PACE nurse, a Sutter PACE medical social worker, and the responsible party (RPP1). R1 did not report that an unauthorized adult entered their room and did not identify any specific incident involving lack of supervision. R1 stated that they felt safe at the facility and responded “Not anymore” when asked if anyone made R1 feel uncomfortable but did not identify a person or event. R3 reported that staff and Staff 3 (S3) are authorized to enter their room and that on one occasion a male maintenance worker entered their room to repair flooring. R3 stated that the worker knocked prior to entering, communicated appropriately, and did not cause them any harm. R3 described the interaction as respectful and professional. R2 did not report any unauthorized entry into their room and did not raise concerns regarding supervision or unauthorized persons entering resident rooms. S3 denied that there had been any incidents involving unauthorized adults entering residents’ rooms due to lack of supervision. RPP1 reported that R1 had stated there was a man in her room; however, RPP1 also acknowledged that R1 experiences delusions, embellishes events, and has cognitive impairment, and RPP1 did not personally witness any adult entering R1’s room. The Sutter PACE nurse and medical social worker both reported that they were not aware of any incidents involving unauthorized adults entering residents’ rooms and had not observed concerns regarding lack of supervision during their regular visits. A review of facility records did not identify any documentation of incident reports of unauthorized entries, supervision concerns, or related incidents. Continued on 9099C Based on the interviews, there is no corroboration of this allegation, and the information obtained does not support a finding. The preponderance of evidence standard is not met for this allegation. Therefore, the above allegation is found to be UNSUBSTANTIATED. Based on interviews with the alleged victim, other residents, the responsible party, facility staff, and independent medical and social service professionals, there is insufficient evidence to support the allegations. No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Grace Bernardino.