complaint·March 30, 2023

Additional interviews were done with three (3) staff between 11:34 a.m.- 12:25 p.m. File review began at 12:30 p.m. and one (1) resident interview at 1:16 p.m. It was alleged that staff are abusing the residents while in care. The Reporting Party (RP) did not provide any further details regarding the allegation. During the course of the investigation, documents obtained, and interviews conducted revealed that there were concerns regarding S1 rough handling residents in care. Documents obtained and reviewed reflected that S1 was provided two (2) coaching (write up) by Gary Lee for four (4) separate incidents reported by either staff or residents. Based on information gathered, S1 was witnessed yelling at two (2) residents, throwing the dining room phone on the floor, and not allowing residents to leave the dining room. On a second incident, it was reported that S1 grabbed a resident by the nose where the resident had a hard time breathing. On a third incident, it was reported that S1 has been very rough with a resident when changing incontinence diapers, and “throws resident around”. Lastly, records reflected that S1 sprayed body soap in a residents’ eyes. During the interview with S1, S1 admitted to spraying residents with incontinence spray on their bodies and hair. S1 further stated that S1 accidentally sprays residents in the eyes if they do not close their eyes when instructed to by S1. Additionally, S1 also admitted that while S1 was playing around with a resident, S1 grabbed residents’ nose too hard stating “I guess I grabbed his nose too hard”. S1 admitted having been abusive towards the residents based on S1’s actions. S1 further explained that S1 has become angry at work due to the environment, being overworked and stressed out. Based on information obtained, the Department has sufficient evidence to determine that S1 abused residents in care; therefore, the above allegation “staff are abusing residents while in care” is deemed SUBSTANTIATED at this time. It was also alleged that staff are yelling at the residents. RP did not provide any further details regarding the allegation. However, interviews revealed that S1 has had at least three (3) incidents involving S1 yelling when other staff had to intervene between residents and S1. Based on information gathered during the course of the investigation, it was determined that staff have witnessed S1 raise their voice and yell at residents. It was further revealed that staff have reported to administration when staff witnessed residents being yelled at. S1 received two (2) write up/coaching for four (4) separate incidents, one of which included yelling at residents. During interview with S1, S1 acknowledged that S1 did yell at the residents and received a coaching/write up. S1 further admitted to yelling at more than one resident and raising S1’s voice on multiple occasions. Based on information gathered, the Department has sufficient evidence to determine that staff yell at residents. Therefore, the above allegation is deemed SUBSTANTIATED at this time. Report will continue on LIC 9099C The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. ED Gary Lee was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted with ED Gary Lee. A copy of the report and appeal rights were provided .