complaint·August 27, 2025

On 07/23/2025 and 08/20/2025, LPA interviewed five (5) staff members (ED, S1-S4) and five (5) residents (R1-R5). ED stated that on 07/06/2025, R1 reported that a caregiver (S5) had entered their room and caused harm. R1’s family expressed concern, and S5 was suspended pending investigation. Law enforcement was contacted and interviewed R1 the same day. No injuries were observed, and accounts of the incident were inconsistent. S5 resigned the following morning. The facility completed an internal investigation, which concluded that no abuse or injuries occurred. R1’s family was satisfied with the facility’s response and requested that S5 no longer provide care to R1. S1 stated that R1 was observed to be anxious and shaken. Staff checked for injuries and none were found. S5 was suspended and later resigned. Hospice was notified and assessed R1, confirming that there were no injuries. R1 did not report the incident again, and R1’s family expressed that R1 was comfortable and that the staff were supportive. S2 stated that R1 had fragile skin and bruised easily. S2 stated that S2 used extra precautions when providing assistance to R1 and asking another staff member for help. S2 reported providing activities of daily living to R1, regularly checking for bruises, and stated that no injuries were observed after R1 reported the incident. R1’s family visited frequently and did not raise concerns. S3 stated that R1 preferred care from specific caregivers and bruised very easily, even with a light touch. S3 stated that hospice staff and caregivers regularly checked on R1 for bruises. R1 was handled carefully, and no injuries or physical abuse were observed. S4 stated that on 07/06/2025, staff reported that R1 appeared upset and faint bruises were observed on R1’s arm. The concern was reported to management, documented, and shared with R1’s family. Law enforcement was contacted and R1 was interviewed. R1 expressed not wanting to leave the facility. No further complaints were made by R1, and no prior history of rough handling was found in the S5’s file. S5 later resigned for other employment. R1 stated that R1 was satisfied with the care and services at the facility. R1 stated that a nighttime staff member had made them uncomfortable, expressing concerns about the staff member’s behavior, and was later terminated. Law enforcement was contacted in response to the concern. R1 expressed feeling comfortable with the current staff and reported no ongoing issues, and stated they were happy living at the facility. Continued on LIC9099-C R2 stated that R2 had not observed or received reports of staff being physically abusive toward residents. R2 further stated that staff were generally respectful and attentive, and that the only concerns raised by residents were related to food quality. R3 stated that R3 likes living at the facility and expressed satisfaction with the care and services provided. R3 further stated that R3 does not have any concerns about staff, describing them as calm, respectful, and helpful, and stated they had not observed or heard of any aggressive or abusive staff behavior. R4 stated that they were comfortable at the facility and stated that staff were polite, attentive, and respectful of individual preferences. R4 further stated that staff were careful when providing assistance and reported not witnessing or hearing of any physically aggressive staff behavior. R4 added that staff appeared well trained. R5 stated that the facility had a positive environment. R5 further stated that staff were gentle, attentive, and respectful, kept their room clean, and that they had not experienced or observed any aggressive behavior from the staff. On 07/22/2025, LPA obtained and reviewed SOC341 and LIC624 Incident Report, dated 07/06/2025, which showed that on 07/06/2025, the facility reported that R1 stated a caregiver had been rough while assisting them to bed and had struck R1’s arm. The concern was reported to management, and law enforcement was contacted the same day. A nurse assessed the resident and observed no injuries. The caregiver, S6, identified in the allegation, was immediately suspended pending investigation and denied that the incident occurred. On 07/22/2025, LPA obtained and reviewed the facility’s internal investigation Report, which stated that law enforcement found the R1’s statements to be inconsistent with the initial allegation. R1 later stated they had fought off attackers, but did not mention facility staff. The staff member, S6, named in the allegation, resigned shortly after the report, citing another job opportunity. Due to the inconsistent statements, absence of injuries, and the staff member’s denial of the allegation, the facility determined the claim of abuse to be unsubstantiated. On 07/22/2025, LPA obtained and reviewed R1’s Pre-Placement Appraisal, dated 09/02/2024, which stated R1 had multiple medical conditions and physical care needs. The record stated that R1 used a walker or wheelchair and required assistance with transferring, showering, dressing, toileting, and medication. Continued on LIC9099-C On 07/22/2025, LPA obtained and reviewed R1’s Physician’s Report, dated 7/14/2024, which didn’t state that R1 had Dementia. On 07/22/2025, LPA obtained and reviewed R1’s Montreal Cognitive Assessment (MOCA) record, dated 9/9/2024, with a score of 13 out of 30. On 07/22/2025, LPA obtained and reviewed R1’s Assessment and Service Plan, dated 07/07/2025, which listed R1’s multiple medical diagnoses. On 07/22/2025, LPA obtained and reviewed R1’s Hospice Notification Record, dated 04/08/2025, stating that hospice services for R1 had been initiated and were being provided by an outside hospice agency. On 08/20/2025, LPA obtained and reviewed a report for a Police complaint. The Law enforcement conducted an investigation following the allegation. The officer reported observing no visible injuries on R1 and found no signs of physical abuse. The case was later closed as inactive by the investigating agency. On 08/21/2025, during the facility visit, LPA observed R1 in the dining hall eating lunch. No visible bruises or injuries were observed on R1. R1 appeared cheerful and was interacting with other residents at the table. Based on observations, interviews, and records reviewed, there was insufficient evidence to support the allegation that a resident was physically abused while in care. 5 out of 5 staff members stated that no injuries were observed on R1 and 5 out of 5 residents stated that no abusive behavior by staff had been witnessed. Law enforcement conducted an investigation, observed no visible injuries, and later closed the case as inactive. The facility immediately suspended the staff member involved and completed an internal investigation, which concluded that the R1’s statements were inconsistent with the allegation and no abuse occurred. Hospice staff and caregivers regularly assessed R1, and no injuries were reported. R1 was observed to be cheerful, with no visible signs of abuse, and expressed satisfaction with care. Given the absence of injuries and corroborating interviews confirming no abuse occurred, the department has determined that the allegation is false, could not have happened, and/or is without a reasonable basis. Therefore, the allegation is UNFOUNDED. No deficiencies were cited under the California Code of Regulations, Title 22. An exit interview was conducted with the Executive Director. A copy of this report was provided to the Executive Director, Tyler Manzo, whose signature on this form confirms receipt of the report.