Complaint·October 15, 2025

(CONTINUED FROM PAGE 1, LIC 9099) A Department interview with Staff #2 (S2) revealed that they were unaware of R2’s phone being taken away. Department interviews with three other residents and a resident’s Responsible Relative revealed that there were no concerns regarding staff taking personal items from residents. There was not enough evidence to support this allegation. Due to a lack of corroborating evidence, the allegation that staff took R2’s phone away is unsubstantiated. Although the allegation may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violation occurred, therefore, the allegation is unsubstantiated. This report was discussed with Cheryl Castro. A copy of this report, along with Licensee/Appeal Rights, (LIC 9058 03/22) were provided. Signature below acknowledges receipt of the documents. *NOTE: LPA left for a 1 hour lunch break and to type all reports related to this complaint. (CONTINUED FROM FIRST PAGE, LIC 9099A) RR also stated that R1’s Primary Care Physician (PCP) had approved the use of restraints on R1 to avoid falls. A records review of R1’s Physician’s Report, dated 11/21/2023, revealed that the PCP approved a “soft tie” for R1 while R1 was seated in a wheelchair to prevent falls. There was no other indication regarding the approval of restraints for a bed. An interview with the Licensee/Administrator confirmed that RR had requested the restrain from the facility and the Administrator believed that the restraint allowed on the Physician’s Report extended to use on the bed. Interviews with two care staff also revealed that they were restraining the resident to the bed and demonstrated the item used to restrain R1. Finally, an interview with R1 revealed that R1 recognized the items used to restrain them and was clearly able to demonstrate the procedure used by staff to restrain them to the bed. There was enough evidence to determine that this allegation is substantiated. Based on the evidence obtained from interviews, observations and a records review, the complaint allegation is substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. A deficiency is cited per Title 22 California Code of Regulation. LPA Silveira conducted an exit interview with Cheryl Castro to whom a copy of this report, the LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Signature below confirms receipt of the reports .