Complaint·March 18, 2026

(Continue from LIC9099) Review of R1’s admission agreement indicated that R1 was admitted to the facility on December 9, 2024. Review of R1’s medical records indicated that R1 was diagnosed with dementia and had previously suffered a stroke affecting speech and mobility. Records also disclosed that R1 had a documented history of aggressive and self-injurious behavior and had previously reported alleged physical abuse at prior placements. Interviews with external sources confirmed that R1 had reported physical abuse at previous placements. Review of facility documentation, including daily progress notes, medical records related to hospital visits, and incident reports submitted to CCL, indicated that R1 experienced multiple behavioral crises requiring transportation to the hospital via 911 emergency personnel. Documentation described incidents in which R1 threw themselves against a wall or onto the bed. Records also indicated that R1 had limited mobility due to the prior stroke and experienced difficulty moving the right arm. In addition, records documented episodes in which R1 expressed suicidal ideation and required transportation to receive a higher level of care. Records further indicated that R1 frequently refused staff assistance with activities of daily living, including eating, changing, and transfers. Review of incident reports submitted to CCL did not disclose any violations in the manner staff responded to or handled these incidents. During multiple interviews conducted during the investigation, R1 denied that staff at the facility had hit or otherwise harmed them and stated that any abuse referenced had occurred prior to moving into the facility. R1 reported that facility staff treated them with respect. During staff interviews, staff and external sources reported that due to R1’s medical condition, R1 often displayed aggressive behaviors toward both staff and themselves. During site visits conducted on November 17, 2025, and December 6, 2025, R1 was observed with no visible signs of abuse or neglect. R1 reported that the bruises referenced in the complaint had resolved months earlier. (Continue at LIC9099C) (continue from LIC9099C) Interviews with staff, external sources and residents did not disclose any corroborating information to support the allegation. Based on observations, interviews, and a review of records, there was insufficient evidence to corroborate the allegation. Although the allegation may have occurred, the investigation did not produce a preponderance of evidence to support that staff hit R1. Therefore, the allegation is deemed unsubstantiated. An exit interview was conducted with Patricia Tapia via telephone. A copy of this report, the LIC 811 Confidential Names List, and the Licensee Rights (LIC 9058 03/22) were provided at the conclusion of the visit.