Complaint Investigation Report

Allegation: Staff are not providing adequate supervision resulting in residents sustaining bruises.

The details of the complaint alleged that (R#1) sustained bruising because of the lack of supervision by facility staff.

On 10/24/2025, during a comprehensive records review, Licensing Program Analyst (LPA) Alfonso Iniguez examined (R#1)’s hospitalization records dated 10/16/2025. The review focused on identifying any documentation that might indicate neglect or inadequate care by the assisted living facility. Upon careful examination, LPA observed that the medical records contained no written statements, physician notes, or diagnostic comments suggesting that (R#1) suffered negligence or harm attributable to their place of residence. The records primarily addressed (R#1)’s medical condition and treatment during hospitalization, with no reference to facility-related concerns. In addition, LPA Iniguez reviewed (R#1)’s Physician’s Report for Residential Care Facilities for the Elderly (LIC 602A) dated 05/20/2025. LPA noted that (R#1)’s documented mental condition may have contributed to their behavior and line of thinking, which could explain certain actions or resistance observed during care.

On 10/23/2025, at approximately 3:30 PM, LPA Iniguez spoke with (W#1). (W#1) confirmed that the facility has contacted them whenever an incident involving (R#1) occurred. (W#1) stated they have not observed facility staff handling (R#1) in a rough manner. Additionally, during visits to (R#1), (W#1) observed that facility staff were present and assisting (R#1) appropriately. Furthermore, (W#1) explained that (R#1) bruises easily because she resists being changed by facility staff. (W#1) indicated this resistance is related to a cultural aspect, as (R#1) does not want to be seen nude by strangers. When such situations occur, (R#1) reportedly pulls herself forcefully, which may contribute to the bruising.