complaint·December 22, 2025

R1’s physician’s report (LIC602) dated November 9, 2022, indicated that R1 is ambulatory and has an underlying medical condition that is described as a progressive brain disorder leading to memory loss, confusion, language problems, and personality changes, per Google AI overview. The report further stated that R1 required full supervision and assistance with activities of daily living. Their underlying medical condition was described as permanent and severe. R2’s LIC602 further describes their mental condition as confused, disoriented, exhibiting inappropriate behaviors, intermittent aggression, wandering, and sundowning. R1’s preplacement appraisal dated November 28, 2023, noted episodes of confusion and the need for R2 to have special observation and night supervision due to wandering. R2’s LIC602 was also reviewed. R2 was non-ambulatory and is a fall risk. They have an underlying condition that, per AI overview, is described as a condition where cells, tissues, or organs progressively break down and lose function over time, which affects their nervous system. They are also diagnosed with a condition that affects their memory. Their LIC602 further shows that R2 is able to follow instructions, communicate their needs, and store their own medications. Resident interviews were conducted. An interview with R1 was attempted but was unsuccessful due to limited verbal skills; R1 only smiled and did not verbally respond. R2 was interviewed and corroborated the incident, stating that R1 entered their room, ignored verbal redirection, slapped them with an open hand, and knocked their glasses off their face. Staff responded to the incident and contacted law enforcement. Staff interviews were conducted. Staff member S1 corroborated the incident, explaining they had left R2’s room briefly to assist another resident. Upon their return, they found R2 crying and were informed that R1 had entered the room and slapped them. S1 observed R2’s glasses knocked off. S1 reported that R1 has exhibited escalating aggressive behaviors, including attempts to hit caregivers and urinating in random areas. Former Executive Director Rebecca Toves arranged for a one to one caregiver contracted by the VA to assist R1 three times per week following the incident. Interviews with outside sources were also conducted. One outside source stated that staffing at the facility was adequate but limited, remarking that “they can only do so much.” Another outside source confirmed that R1 received VA assistance after the incident. Law enforcement corroborated that they had responded to the facility on multiple occasions for incidents involving R1, including altercations with other residents resulting in minor injuries. R1 was described as frequently getting into altercations and sometimes becoming violent. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff, resident, and outside source interviews, and records review, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099D. The report was discussed, a plan of correction was jointly developed, and an exit interview was conducted with RSD Richard Tibi, to whom a copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22) were provided at the conclusion of the visit. The signature below confirms the receipt of these documents.