complaint·September 29, 2025

***This is an amended report *** Responding Officer (RO), interviewed staff to determine how the incident occurred. S3 had informed RO that R2 had physically assaulted another resident in the past with a footrest from a wheelchair. S3 also added that when new residents move in the staff monitor them for 48 hours checking on them and making sure they are adjusting to their environment and staff conduct status checks every hour. During the investigation, RO was informed by S4 that he/she had just recently been hired on and was in training and onboarding and did not have the opportunity to review residents’ files or conduct follow-up assessments for residents like R2 regarding change of condition. It is unclear what action was taken after R2 had assaulted the previous resident R3. R2 continued to reside in the room without a roommate for over a month until R1 was assigned to that room. S4 informed RO that S4 did not check the diagnoses or care plans of the residents to see if the residents were compatible before moving them in together. It was reported by staff that R2 preferred to be alone and by himself/herself, R2 was not sociable with other residents and only engaged with the staff. R2 had panic attack disorder and anxiety, a mental health condition that should have been addressed to determine if R2 was suitable for the facility. S4 admitted to not reviewing service plans for residents and did not have the opportunity to address any change of conditions with the residents due to onboarding and trying to manage S4s responsibilities. S4 also mentioned that the facility was using outside agencies for caregivers and attempting to hire more staff. After the former RSD left some of the caregivers also left leaving them understaffed. Based on records review, R2 has had experiences of panic disorder which happens with sudden attacks of intense anxiety that occur without any specific trigger or situation. There is no record of reappraisal when the first incident happened with R3. Therefore, in the matter of Neglect/Lack of Care and Supervision resulting in R1 being assaulted by R2, the findings are substantiated. At the time of the complaint inspection on 8/8/2024, licensee was informed that the incident is currently under review and a future civil penalty may apply based on Health and S afety Code § 1569.49. Based on observations and interviews which were conducted and record reviews, 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. Report is reviewed and a copy of the report and Appeal Rights is provided.