complaint·July 22, 2025

On 11/06/2024, the Department conducted a case management visit to follow-up on this incident after receiving a self-reported SOC-341 from the facility. See case management on 11/06/2024. During this visit, R1 was interviewed and was unable to recall the incident occurring. R1’s family member was informed of the incident. The Executive Director (ED) stated that based on their internal investigation, S1 stated that he/she does this with R1 in a joking way where sometimes S1 would test R1’s strength. At the time of the interaction, R1 was not participating in the joke and seemed startled. S1 was terminated following the incident for inappropriate behavior with the resident. The local police department was notified and responded to the incident on 10/27/2024. Based on record review, R1 did not sustain any injuries and did not recall the event. The police obtained information of S1 and was identified and outstanding at time of the event. On 03/24/2025, the Department received a cross-report of the same incident and generated a complaint investigation. On 04/03/2025, 4 additional staff members were interviewed for the complaint investigation. Based on staff interview, it was stated that R1 was restrained by S1 and verbally challenged to attempt to raise his/her arm as an exhibition of strength. When the Executive Director (ED) interviewed S1 following the incident, S1 stated the incident was only a playful interaction with R1. The incident was witnessed by a staff (S2) who immediately stopped the interaction. Based on interview with S2, it was stated that S1 approached R1 from behind and held R1’s wrist on the side of his/her chair restricting R1’s movement. S2 stated that R1 had a distress look on his/her face during the interaction. S2 stated to have immediately called out S1’s name who immediately released R1’s wrist and reported to S2. S2 reminded S1 to not interact with the residents in that manner and to be careful of his/her action. The observation was then reported to management. The Department has investigated the above allegation. Based on interview and record review the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. A deficiency was cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Rachel Brown and a copy of the report and appeal rights were provided. Page 2 of 2.