Complaint·February 11, 2026

(Cont. from LIC 9099) I nterviews with staff corroborated the allegation. By admission, staff reported that a fabric tie was used to secure Resident 1 (R1) in a wheelchair to prevent them from falling forward. Staff reported that the resident was unable to release the tie independently. Staff stated that the restraint was applied periodically when the resident was seated in the wheelchair and staff were not present to monitor R1 in the living room area. Staff confirmed that the restraint was removed after being advised by a social worker that its use was not permitted. LPA reviewed R1’s physician report and hospice records. No physician order was found authorizing the use of any postural support for R1. Hospice records revealed that R1 is bed-bound and wheelchair bound, requires one person assistance for transfers, and has upper extremity stiffness. Hospice documentation also noted that caregivers are to receive instruction on fall precautions and safe use of assistive devices. LPA observed the fabric tie used to secure R1, observed as a scarf-like cloth. Staff demonstrated how the tie was applied around the resident’s lower torso to hold R1's posture in the wheelchair. LPA observed R1 in bed, clean, well-groomed and asleep. Staff showed LPA the wheelchair used by R1 but did not apply the restraint to R1 for demonstration during the visit due to R1 being asleep. Based on observations, interviews and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.  California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Licensee Leonor Carmona, whose signature below confirms receipt of these rights.