Follow-up on corrections·March 18, 2026

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted a Case Management visit to cite a deficiency disclosed during a complaint investigation conducted on December 6, 2025. LPA met with Licensee Patricia Tapia via telephone and discussed the details of the violation. During staff interviews conducted during the complaint investigation, it was disclosed that there have been multiple incidents of verbal abuse between two residents, in which Resident 1 (R1) has been the target of verbal aggression by Resident 2 (R2). Both residents have been roommates for an extended period of time. Records reviewed indicated that R1 has resided at the facility since December 2020 and R2 was admitted in September 2023 when they became roommates. Staff were provided with LIC811 to identify R1 and R1 for plan of correction. Staff interviews indicated that the verbal abuse began around July 2025, when R2 experienced a change in condition and began directing verbal aggression toward R1. Staff reported that the incidents involved R2 yelling at and verbally targeting R1 on multiple occasions. Staff further reported that on November 25, 2025, R2 threw a water bottle in the direction of R1. The water bottle did not strike R1 and R1 did not sustain any injuries. Staff indicated that the incident was addressed internally by staff; however, it was not reported to Community Care Licensing. (Continue at LIC809D) (Continue from LIC809) During interviews conducted with staff, it was confirmed that none of the incidents involving R2’s verbal aggression toward R1 had been reported to Community Care Licensing as required by California Code of Regulations, Title 22. Staff stated that the incidents were not reported because they believed R2’s aggressive behavior was related to R2’s documented dementia diagnosis. The California Code of Regulations, Title 22, requires licensees to report incidents involving resident abuse, including verbal abuse and aggressive behavior between residents that may threaten the health, safety, or personal rights of a resident. Based on staff statements and information obtained during the investigation, the facility failed to report the incidents involving R2’s verbal abuse toward R1, including the incident on November 25, 2025, in which R2 threw a water bottle toward R1. Pursuant to the California Code of Regulations, Title 22, Division 6, a deficiency is being cited on the attached LIC 809D. The facility was advised that the November 25, 2025 incident must be documented and reported to Community Care Licensing. In addition, a plan of correction was developed with Licensee Patricia Tapia. An exit interview was conducted with Licensee Patricia Tapia, to whom a copy of this report, the LIC 809D Deficiency Report and LIC811 Confidential Names form were provided at the conclusion of the visit.