Complaint·April 4, 2024

Staff 1 (S1) arrived at the area and separated R1 and R2 and documented the event on an Incident Report. R1 complained of pain the next day but it subsided later that evening. Staff interviews indicated R1 received a fingerprint size bruise on their shoulder. The residents and others in the area were contacted for their observation. Most of the residents contacted had Dementia diagnoses and were unable to provide statements. R1 provided their account which is consistent with the allegation reported to CCLD. R2 provided a statement saying they were sorry for striking R1. R3 was interviewed and said they did not see the incident. When asked, R3 said they never witnessed any resident strike another resident during the time they lived at the facility. LPA contacted an outside agency regarding the incident. LPA asked the outside source if they observed concerns with a lack of supervision at the facility. The outside source reviewed their records and found no complaints or related visits regarding a lack of supervision. Records were reviewed, including staffing schedules. LPA found no evidence of staff shortages. Per Staff 2’s (S2) interview and staffing level record review, there were three staff working on the day of the incident. S2 said the shift was fully staffed. S2 conducted a post-action review of the incident and did not identify lack of supervision as a contributing factor. Per S2, S1 was in the dining area at the time of the incident. S2 said the altercation happened quick but S1 was able to respond and address it immediately. LPA asked S2 about the Incident Report submitted to CCLD. The report referenced counseling was provided. S2 said the term counseling referred to communication/training regarding R2’s updated care plan was disseminated to all staff. S2 said R2’s care plan was modified in response to R2’s change in behavior. LPA interviewed S1. S1 said they were in the area when the incident occurred. S1 witnessed R2 squeeze the area of R1’s arm. S1 observed no immediate markings but said a bruise appeared on R1, 2-3 days later. S1 was in the kitchen when they heard R1 yell. S1 responded to the scene immediately and redirected the two residents. S1 said they asked residents in the area what they observed but none of the residents reported seeing anything. S1 said neither resident required one-on-one supervision or had a history of aggressive behavior. S1 prepared the LIC624 report documenting the incident. The Department has investigated the allegation that lack of supervision resulted in resident-on-resident abuse. Based upon interviews with residents, staff, and outside sources, no corroboration or information was obtained to support the allegation. No evidence was obtained to prove the incident occurred due to a lapse in supervision by staff. The Preponderance of Evidence standard was not met. Therefore, the allegation is Unsubstantiated. An exit interview was conducted with Ms. Guerrero and a copy of this report was provided to Ms. Guerrero whose signature below confirms receipt of copies of this report and Licensee Rights (LIC 9058).