complaint·December 21, 2024

Page 2 of 2. On 9/14/2023, the Department interviewed 6 facility staff (S1-S6). All six staff stated on 9/5/2023, the resident lost consciousness during lunch time and staff were present in dining room and observed R1 and called 911 right away. Six out of six staff stated R1 was combative and sustained injuries when exhibited combative behavior. Six of six staff stated they have not seen or heard staff hurting or physically abusing R1 or other residents. Six out of six staff stated they have seen resident hurting or physically abusing R1 or other residents. Three of out the six staff provide direct care and supervision to R1. All three staff stated R1 has had combative behaviors where R1 will hurt themselves by hitting the side rails or the walls when R1 is agitated. On 9/14/2023, the Department was not able to interview residents at the facility due residents not responding or refusing to answer LPA’s questions related to the investigation. Based on review of R1’s documents, R1 has a neurocognitive disorder and history of skin bruising to due agitation. Based on review of R1’s Physician’s Report dated 5/17/2023, R1 is diagnosed with neurocognitive disorder and was diagnosed with nontraumatic subdural hematoma. Based on review of Incident Reports from 8/22/2023 – 9/5/2023, facility staff observed self-inflicted bruising due to R1 falling from bed. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator, Beverly Canate and a copy of the report was provided.