complaint·March 27, 2026

Facility staff stated that R1 was now a two person assist, required the use of a restraint, and needed a level of care that the facility does not provide. Hospital personnel indicated that there were no medical orders supporting these claimed changes and that they were prepared to discharge R1 to their home at the facility. LPA interviewed the Resident Services Director (RSD), who confirmed that R1 is not currently residing at the facility. The RSD explained that the facility declined R1’s return due to what they believed was a change in R1’s care needs. According to the RSD, they received direction from the facility’s corporate medical staff, who advised them that R1 required a higher level of care and should not be accepted back. LPA reviewed an email chain between facility management and the Director of Community Nurse Support. The nurse support director stated that the facility did not have adequate staffing to meet R1’s needs. These were described as requiring two person transfer assistance, use of a wheelchair with a hemi tray (considered a restraint because R1 cannot remove it independently due to altered cognition and dementia), and assistance with repositioning, which would classify R1 as bedbound according to the facility’s internal standards. The facility claimed that these needs exceeded the level of care they could safely provide. Through record review and interviews, LPA determined that the facility refused R1’s return without following required eviction procedures. R1 was not given a written 30 day notice, relocation planning assistance, or any of the mandated documentation required by Title 22 and the Health and Safety Code. R1 was medically cleared to return, had an established residence at the facility, and was prepared for discharge; however, the facility’s refusal left R1 at the hospital without a lawful or approved discharge and without a safe relocation plan. The refusal to readmit R1 under these circumstances constitutes unlawful eviction and abandonment. Based on the information obtained, including interviews and documentation reviewed, the allegations of staff abandoning R1 at the hospital and unlawfully evicting them are substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099-D. The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Richard Tibi. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22), were provided to Richard Tibi at the conclusion of the visit. The signature below confirms the receipt of these documents.