Inspector’s narrative
What the inspector wrote
The notice indicated the cause of eviction included behaviors by R1 that constituted “harassment or psychological abuse or causes mental suffering of an elder or dependent adult.” It was alleged if the behaviors rose to the level supporting an eviction notice, then the Administrator and staff, as mandated reporters, should have reported the abuse to Community Care Licensing (CCL), the local Long Term Care Ombudsman (LTCO) program, and local law enforcement using the SOC341 forms.
Interviews conducted with residents indicated that R1 discouraged them from sitting with preferred companions, interfered with group participation, and was observed repeatedly raising their voice and talking rudely to staff. Two residents stated R1 repeatedly entered another resident’s apartment uninvited to complain, as this resident was the resident council president, but was on Hospice. Multiple residents reported avoiding dining and activities due to R1, some observed other residents crying after interactions with R1, and two residents stated they would move out if R1 remained.
Resident Services Coordinator stated during interview R1 was overheard calling residents “dumb” or “not smart,” told some “you don’t belong,” and created a hostile environment. Staff interviewed stated they observed R1 yelling at residents and staff. On one occasion Staff 8 (S8) witnessed R1 throw a purse at a resident over a seating dispute on the bus. Staff noted residents with mild cognitive impairment were targeted and staff claim that some residents feared retaliation if they reported an incident and R1 found out about the report.
LPA obtained facility forms titled “Resident/Family Grievance report”. Twenty-two (22) forms were collected, all regarding R1. Eleven (11) of the twenty-two (22) forms document events between 07/03/2024 and 03/09/2025 of R1 refusing seating or activity participation to other residents, repeated unwanted phone calls to Resident 10 (R10), loud/banging noises affecting neighboring residents, demeaning comments to staff, misuse of laundry machines causing disruption in other residents using them, and multiple resident/staff grievances.
LPA received an Incident Report from 11/23/2024. The incident report documented a resident reporting to the facility that they were being harassed by R1, R1 was calling their cell phone repeatedly, and resident reported they felt very uncomfortable around R1 because they feel pressured or manipulated to join activities and meals. Continued on 9099-C
A letter dated 12/05/2024 was sent to LPA Rankin documenting instances of R1’s insulting and rude behavior to other residents causing them distress, rejecting residents from playing games, persistent unwanted phone calls to residents, loud noises in R1’s apartment, and screaming at staff.
Additional documents collected include letter correspondence and an eviction notice for R1. A letter from 11/15/2024 documented verbal harassment of staff, screaming and insults; R1 was reminded harassment violates resident handbook. A letter from 11/28/2024 documented other residents feeling harassed, receiving unwanted attention, and feeling targeted; R1 was instructed harassment must cease and was warned against retaliation. A letter from 12/11/2024 documented turning away a resident from seating, rude conduct, persistent complaints; it was reiterated to R1 harassment was prohibited. A letter from 01/02/2025 noted harassment toward servers. R1’s eviction notice includes summaries of fifteen (15) instances where R1 verbally berated, yelled, and pressured or mistreated staff; and four (4) instances involving R1’s treatment of residents, which were corroborated by the interviews and grievance reports. Although a majority of the reported mistreatment was directed toward staff, residents were also present for some of these incidents and observed these interactions, which, according to interviews and grievances, created an environment of fear and psychological distress for residents, and disrupted their sense of safety and well-being.
California Code of Regulations Title 22 87211(a)(1)(D) states the licensee must submit a written reporting to CCL within seven (7) days of “Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.” Mandated reporters must report abuse using form SOC341 per the definitions in Welfare and Institutions Code (WIC) §15610.07(a)(1) [“Abuse of an elder or a dependent adult” means any of the following: Physical abuse, neglect, abandonment, isolation, abduction, or other treatment with resulting…mental suffering.”] and WIC §15610.53 [“Mental suffering" means fear, agitation, confusion, severe depression, or other forms of serious emotional distress that is brought about by forms of intimidating behavior, threats, harassment, or by deceptive acts performed or false or misleading statements made with malicious intent to agitate, confuse, frighten, or cause severe depression or serious emotional distress of the elder or dependent adult.”]
Continued on 9099-C
The evidence shows that R1’s behaviors constitute incident(s) that threaten the welfare and safety of residents and aligns with the definition of treatment resulting in mental suffering. The evidence demonstrates a pattern of psychological harassment by R1 toward staff and other residents, which negatively impacted the facility environment. Despite being aware of these effects, neither the Administrator nor staff submitted SOC341 reports to CCL, nor to LTCO or law enforcement as required per Welfare and Institutions Code (WIC) 15630.
Based on interviews and documentation, there is a preponderance of evidence that the facility failed to meet mandated reporting requirements regarding suspected psychological abuse/mental suffering. Therefore, the allegation is substantiated at this time. This case will be cross-reported to California Department of Justice/Division of Medi-Cal Fraud and Elder Abuse (DOJ/DMFEA) and local law enforcement for failure to follow mandated reporter requirements.
An exit interview was conducted, deficiency cited on 9099-D, a copy of this report and the appeal rights was provided.
