Complaint Investigation Report

LPAs P. Manalo and K. Nguyen conducted interviews with 4 residents and 4 staff.

Allegation: Staff do not report incidents to appropriate parties

It was alleged that staff do not report incidents to appropriate parties. A review of R1’s Resident Daily Log dated 03/09/2025 and Internal Incident Report dated 03/09/2025 and 04/23/2025 revealed that R1 had multiple unwitnessed falls. Falls were made aware to the responsible parties, however, were not reported to the licensing department. Based on interviews conducted with S2, S2 stated that incident reports will only be reported to the licensing department if the resident was sent to the hospital or had any serious injury due to previous training from the facility.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of this report and appeal rights provided.