Complaint·August 19, 2025

S1 explained the rubber bands were used to hold the doors closed due to the light shining from R1’s room into the hallway. R1 was not treated with dignity when S1 goosed R1, by poking R1 in between their buttocks and using rubber bands to hold R1’s doorknobs closed. The licensee’s interview revealed they removed S1 from providing care to R1 and R1 is no longer sleeping in the hallway in front of R1’s room. S1 is currently residing in the garage. The administrator was made aware staff are not allowed to sleep in the garage unless approved by the Fire Department. The licensee stated they will submit documentation for the fire department review. Based on LPA’s observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Sheik Hafiz whose signature below confirms receipt of these rights. S1 stated there was no scratch or injury that occurred. S1 stated, R1 scratched their hand on their walker. S1 offered to clean the skin tear, but R1 refused, it’s unknown how exactly R1 sustained the scratch. Outside source interview revealed the day the resident stated the incident occurred, there were no visible scratches or wounds. R1 also stated the same incident occurred at their prior facility. LPA observed the wall in the bedroom that R1 stated they were pushed against and noticed it was not possible as there was a bed located in the area reported. Resident interviews revealed they have never been pushed or injured by staff. Residents also reported not being aware of the incident. Staff interviews revealed they have not witnessed or heard S1 push R1 against the wall. Staff interviews stated R1 had a scratch on their hand, but they didn’t know how R1 sustained it. It was also alleged that S1 locked R1 in their room by tying rubber bands around the doorknobs to lock R1 in their room. S1’s interview revealed they were sleeping on a cot in the hallway located outside of R1’s room. S1 stated they used large rubber bands around the two (2) doorknobs to hold the door closed due to the lighting coming through the door opening. The double doors to R1’s room do not close completely, allowing lighting through the opening of the double doors. S1 explained the door was not locked with the rubber bands, as the doors could easily be opened. R1’s interview confirmed their doors were never locked and they were able to enter and exit their room at any time. R1 was not aware of any rubber bands on their doorknobs. It was also alleged that staff did not ensure R1 had access to incontinent equipment. It was reported that staff were hiding R1’s urinal at night. R1 is able to ambulate and use the restroom independently. R1 has a urinal for nighttime use to ensure safety from getting up to go to the bathroom at night. On 02/03/25, LPA observed two (2) urinals located in R1’s bedroom. R1 denied not having access to their urinal. Staff interviews confirmed R1 has two (2) urinals for nighttime use, as R1 uses the bathroom independently during the day. Staff explained that the urinals are only taken by staff to discard the urine and clean the urinals, then it’s returned to R1. R1 denied not having access to their incontinent equipment. Lastly, it was alleged that staff did not refill R1’s medications. R1’s responsible party’s interview confirmed that they manage R1’s finances and the out of pocket cost for the medication was costly. Therefore, they didn’t always purchase it for R1. Also, due to R1’s medical insurance, some medications were held. R1’s responsible party explained the facility was not responsible for any errors with R1’s medications and R1’s primary care physician (PCP) was involved. R1’s responsible party also indicated R1’s physician’s assistant was calling in the refills to the pharmacy not the facility. In addition, R1 was no longer taking the medication in question, therefore, it was not refilled. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Sheik Hafiz whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1 and Staff #1]