Complaint·April 24, 2026

On 11/19/2025 the Department conducted a complaint investigation visit and interviewed 8 Staff (S1 to S8) and 1 Resident (R1). 8 Out of 8 staff stated he/she had heard about R1 sustaining an injury to his/her head on 11/14/2025. S7 stated he/she observed R1 ‘down the bed" on 11/14/2025 during the evening shift (2:45PM to 11:00PM). S7 stated he/she placed a bed sheet underneath R1 and then began pulling R1 up, when R1 stated “we bumped my head.” S7 stated a pillow was placed at the top of the bed before he/she moved R1 in the bed. S7 stated he/she then checked R1’s top of the head and observed a ‘red spot, less than an inch large’ and the area was not open (not an open wound). S7 stated he/she reported this incident to the MedTech on duty on 11/14/2025. On 11/19/2025 the Department interviewed R1. R1 stated a staff ‘pulled him/her up, hit on the wall.” R1 did not provide additional information regarding this incident. R1 was observed with a bandage on the top of his/her head during the interview. Review of R1’s physicians report dated 5/16/2023, R1 does not have a history of skin breakdown and is able to follow instructions. Review of R1’s care plan dated 3/25/2025, for transferring, R1 level of assistance is noted as ‘extensive-Resident requires frequent hands-on assistance with transfers and or changes in position. The care plan also does not require a two person assist with transfers. Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be substantiated . California Code of Regulations Title 22, are being cited on the attached LIC 9099 D. An exit interview was conducted with GM Candace Bolin, and a copy of this report and appeal rights were provided. Page 2 of 2 END OF REPORT