Complaint Investigation Report

157209316-1-15-2025-24-AS-SPIY-DCYSDX-20250116124752

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

This is an official report of an unannounced visit/investigation of a complaint received in our office on

10/03/2024 and conducted by Evaluator Rachel A Bruce

COMPLAINT CONTROL NUMBER: 24-AS-20241003151606

Staff inappropriately restrained the residents

On January 9, 2025, Licensing Program Analyst (LPA), R Bruce conducted a subsequent complaint investigation visit to the facility. During the course of this complaint investigation LPA interviewed staff, clients family, hospice worker, and LPA also obtained and/or reviewed facility records.

It was determined based on the interviews, photographs, and records review that the above allegation is SUBSTANTIATED. Facility did inappropriately restrain a resident in her wheelchair utilizing a bed sheet tied around the client and chair to prohibit and prevent client from falling. There was no indication in the client's file that the doctor or family was made aware or approved.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, are being cited on the attached LIC 9099D.