Complaint·June 5, 2025

(continued from 9099) Page 2 of 3 Interviews reveal on 02/13/2022, S1 reportedly attempted to help Resident#2(R2) change their incontinence brief. Resident #1(R1) began to hit S1 in the back, while S1 was helping R2, and was reported to have attempted to put S1 in a choke hold while yelling at S1 to “leave [R2] alone”. S1 admittedly grabbed R1’s wrists to try to remove R1’s arm from around S1’s neck. When that did not work, S1 reported they began to strike at R1’s hand with a closed right fist until R1 let go and S1 could free themselves. S1 reported the incident to Staff #2 (S2). The altercation resulted in bruising and skin tears of R1’s hands and wrists on both the right and left limbs. Staff interviews corroborated the details of the incident. When a staff member asked R1 what happened, R1 pointed to S1 and confirmed that they had caused the injury. Due to R1 diagnosis of dementia they could not provide any other statements about what happened. R2 is also diagnosed with dementia and could not provide a statement about the incident. S2 reported this incident to their supervisor, Staff #3 (S3), who also reported the incident to their supervisor, Staff #4 (S4). In addition to S1 causing bruising to R1, the Licensee did not report this incident to the licensing agency. [See LIC 811 Confidential Names List for a description of R1, R2 S1, S2, S3 and S4] Staff interviews and resident family interviews reveal other incidents where S1 has been inappropriately rough with residents in care or verbally abusive with residents in care. Department Interview with the executive director reveal S1 is no longer working at the facility. (continued on LIC 9099) (continued from LIC9099-C) Page 3 of 3 Based on S1’s own account of events, interviews with staff and outside sources, records review, and photographs evidence of bruising healing over time, a preponderance of evidence exists supporting that facility staff handled resident roughly, resulting in bruising. The allegation is, therefore, Substantiated. One (1) deficiency was cited per the California Code of Regulations, Title 22 (refer to the LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee and the licensee staff. An exit interview was conducted with Administrator Nora Garza, to whom a copy of this report, the LIC 9099-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (continued from 9099) Records review reveal resident #1 (R1) moved into the facility on 06/02/2021. A review of records also reveal while R1’s assessment documented the need for stand-by assist for showing upon move-in, R1’s plan of care indicated that R1 was independent for showers and R1 only needed assistance with dressing and prompting. Dressing and prompting were described as assistance with selecting an outfit for the day, prompting to shower, and checking back later to see if the shower was taken. Staff interviews supported that R1 was not receiving stand-by assist but rather that R1 was receiving services as outlined in the care plan of dressing and prompting assistance. A service plan log for recording daily care by staff indicated that stand-by assist was indeed provided in the months of July and August through the period in time at which a reassessment was done on 08/26/2021. The department records review of daily logs initialed by staff show that stand-by assist was provided for July and August. Facility staff could not produce a service plan log for June as there was a change in staffing and records for June could not be located. A review of R1's reassessment at the end of August 2021 deemed R1 independent for showering. Therefore, according to records stand-by assist was provided and was a higher level of care than indicated on the care plan. Records review showed that more care was provided not less than was outlined in the care plan. An interview was attempted with R1 but due to dementia diagnosis, no pertinent information was obtained. Due to facility staff being able to provide documentation of more care being provided to R1 than outlined in the care plan and due to contradicting evidence with interviews and records review, this allegation is found to be UNSUBSTANTIATED. An exit interview was conducted with Administrator Nora Garza. A hard copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Administrator at the conclusion of the visit.