Complaint Investigation Report

Regarding the allegation: Facility staff did not provide a safe/comfortable environment for residents in care. It is alleged that the facility staff are not providing a safe and comfortable environment for resident #1(R1) in care and is Resident #2 (R2) is constantly verbally abusing R1 and staff are not expressing concerns about R1's safety. Five (5) of five (5) staff interviewed deny this allegation, staff stated they are keeping a watchful eye over the residents that exchange verbal insults and have redirected residents when conflicts between residents R1 and R2 arise. Two (2) of five (5) staff interviewed stated they have observed R2 verbally abusing R1 and have intervened and redirected R2. Three (3) of Five (5) staff stated R2 constantly is verbally abusing R1. The Administrator is aware of the history between R1 and R2 and has not created plan of moving R1 to another room. According to Witness #1, the facility has three empty shared rooms #107, 113 and 201 and one empty bed in rooms 224 and 119, therefore Administrator could have prevented this incident from occurring. Four (4) out of seven (7) residents interviewed stated they do not feel safe residing at the facility, due to residents becoming unruly and display behaviors of yelling, cursing and sometimes throwing things to the floor and breaking them resulting in other residents becoming afraid of unruly residents behaviors. R1 & R2 were roommates, altercations between R1 & R2 occured 07/24/25 and 08/06/25 and 10/28/25 and that the administrator was aware that R1 was being verbally abused by R2 and R1 and R2 were no longer compatible as roommates, however, the administrator did not create a plan to separate the R1 and R2. Administrator provided new room for R2 during today’s visit. Based on LPA's observations and interviews which were conducted and record reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, (Title 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.

Exit interview was conducted, copy of 9099, 9099C, 9099D and appeals report were provided to the Administrator Gil Agas.