complaint·September 12, 2025

observed grabbing or pulling on the staff. Staff did not demonstrate knowledge of appropriate de-escalation techniques. Interviews with two (2) residents did not yield any consistent accounts of any altercation. The residents reported that R1 had medical behaviors. R1 was not cooperative with the staff. OS3 was interviewed and stated that the facility staff conducted a pre-appraisal review and stated that they can care for residents with dementia and behaviors related to dementia. On April 20, 2023, an allegation was made that facility staff left a resident on the floor for an extended period after falling. LPA conducted interviews with staff members who provided statements confirming that they responded promptly to the resident's lying on the floor and followed proper procedures. The staff were aware that the resident has a right to not be forced to get up from the floor. R1 did get up off the floor on their own when they were ready to get up. The LPA interviewed the residents, who confirmed that staff respond quickly to falls and provide necessary assistance. Reviewed incident reports related to falls and found no evidence of staff leaving residents on the floor fo r extended periods. LPA Domingo verified that staff employed at the time of the report have completed training in emergency response and fall management as per Title 22 regulations. On April 20, 2023, an allegation was made that facility staff inappropriately punished a resident. LPA Domingo conducted interviews with staff members who confirmed that they follow proper disciplinary procedures and respect resident rights. LPA Domingo interviewed other residents who confirmed that they have not experienced or witnessed inappropriate punishment. Interviews with Outside sources confirmed that they have not witnessed inappropriate punishment or treatment from staff to residents. Records reviewed revealed that staff have resident rights training every year. On April 20, 2023, an allegation was made that the facility staff did not adequately manage the resident's medication. LPA Domingo conducted interviews with staff members who confirmed that they follow the medication management procedures. Interviews were conducted with two (3) staff members responsible for medication administration. Staff demonstrated knowledge of the facility’s medication policies and procedures, including proper documentation, storage, and administration protocols. Staff confirmed they had received training in medication management as required by Title 22, Section 87465, and were able to articulate steps taken to ensure medication is administered accurately and timely. (This is an amended report. page 2 of 3) Interviews with two (2) residents revealed no concerns regarding medication administration. Residents stated that they receive their medications consistently and as prescribed. One resident stated, “They always bring my medication on time and explain what it’s for if I ask.” Outside sources were interviewed, and they all stated that they have no concerns regarding the facility staff administering their medications properly and consistently. A review of Medication Administration Records (MARs) for a sample of residents showed no discrepancies. Medications were documented as administered according to physician orders. No missed doses or errors were identified during the review period. Staff training records confirmed that all personnel responsible for medication administration had completed required training, including annual updates, in accordance with Health and Safety Code and Title 22 regulations. The department has investigated the above-mentioned complaints. The Department has found that although the allegation may have occurred or be valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur; therefore, the allegations are unsubstantiated . This is an amended report page 3 of 3