Complaint·July 29, 2025

Interview with S1 confirmed that residents, “have too drink water” without additional explanation on why residents are required and cannot choose whether they want to drink water. This was observed not in compliance with Title 22 regulation 87468.2(a)(3) Additional Personal Rights of Residents in Privately operated facilities.The facility did not ensure that residents in care were protected from coercion. Interviews and observations revealed that staff were requiring residents to drink a specific amount of water determined by the facility, and residents were reportedly not permitted to leave the table until they had complied. Staff are inappropriately restraining a resident in care It was alleged that staff inappropriately restrained a resident in care. Staff were observed tying an apron around the waist of a resident in care. This investigation consisted of facility observations, interviews with staff, and records review. On 7/1/2025 LPA Hughes conducted an unannounced facility visit and observed resident (R3) sitting at the dining table having lunch, with a helmet on their head. On 7/25/2025 LPA Gould conducted an unannounced facility visit, and observed two gait belts on the kitchen table, per LPA Gould, interview with 1 out of 1 facility staff indicated the belts are used for R1 and R3 to secure the residents to the kitchen table chairs. Facility staff demonstrated how the Gait belts are used on LPA Gould, while sitting at the kitchen table, securing the LPA to the kitchen chair. On 7/29/2025 LPA Hughes conducted an interview with facility administrator, administrator stated that gait belts are used to guide the residents. Resident (R3) wears a gait belt whenever she is unsteady. A review of resident (R3) LIC 603A Resident Appraisal indicates that resident’s ambulatory status and functional capabilities do not require the use of assistive devices such braces or crutches. However, R3 has a physician’s order on file indicating the use of a gait belt for assistance with mobility/transfers with staff support. The order does not specify the use of a gait belt for the purpose of securing the resident to a chair. This was observed not in compliance with Title 22 regulation 87608(a)(5) Postural Supports. The facility did not ensure that residents in care were assisted in a manner that upholds their personal rights, including freedom from being physically restrained or tied. As a result, these allegations 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 with Lita S and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.