Complaint·November 22, 2024

S1 has been observed including but not limited to twisting resident's wrists while changing/cleaning resident to force resident to comply with prompts, pulling a resident's hair and stepping on that resident's foot, forcing residents to sit down at a chair and shoving the table so close to them they cannot get up, leaving residents in postural support chairs to restrict their movement, yelling at residents who do not understand S1 due to a language barrier, and changing a resident's briefs while standing in the hallway not affording the resident privacy or dignity. On 07/11/2024, the allegations in complaint # 29-AS-20230613124133 against S1 were deemed Substantiated, and deficiencies were cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Licensee agreed to a conducted training by an outside vendor with S1 regarding personal rights of clients as well as communication training and submit evidence to the Licensing Agency by 7/19/2024. Based on the information gathered, there is sufficient evidence to prove the alleged violation occurred. Therefore, the allegation is substantiated. Exit interview conducted. Copy of this report provided to the facility. Previously, complaint ## 29-AS-20230613124133 received by the Licensing Agency on 6/13/2023 had the allegation "Facility does not have enough staff to meet the needs of residents in care" deemed unsubstantiated on 7/11/2024. Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated. Exit Interview Conducted. Copy of this report provided to the facility.