Complaint Investigation Report

interviewed residents from 01:08PM to 02:34PM. During an additional subsequent complaint visit conducted on 05/28/2025, LPA interviewed Administrator at 01:35PM, interviewed staff at 02:30PM and 02:36PM and LPA briefly toured the facility with Administrator at 02:46PM. During today’s visit, LPA toured the facility with staff at 01:30PM, interviewed 1 (one) resident and 1 (one) resident’s family member, and LPA reviewed and obtained copies of pertinent documents. Throughout the course of the investigation, LPA Dulek reviewed all documents obtained. The following was then determined:

Allegation: “Staff violated resident’s personal rights:”

The complaint alleges that R1 was never taken outside the facility nor was R1 transferred out of their bed during the time R1 lived at the facility. Additionally, reporting party indicated the television in R1’s room was broken and R1 was left in their room by themselves with nothing to watch. During all 3 (three) visits at this facility, LPAs observed that all non-ambulatory residents were in their own rooms. LPAs observed no planned activities occurring. Residents interviewed stated they remain in their beds during the day, as staff do not give them the option to get up. One resident reported that they are able to use the restroom with transfer/escort assistance and they prefer to use the restroom for their toileting needs. However, this resident reported that care staff have told the resident to use their diaper, and the staff will provide incontinence care for this resident. This resident and their family member both stated that the resident has only gotten out of bed 2 (two) times in the 2 (two) months they have lived at the facility because it is too difficult for the staff to lift the resident. Resident stated they would prefer to get out of bed daily and exercise their legs. Although LPA was unable to interview R1 related to this allegation, on 06/19/2025, LPA confirmed the television in the room R1 lived in does work but is difficult to operate. The resident required assistance from the LPA to operate the television, as the resident was unable to read and follow the written instructions for the television. R1’s preplacement appraisal information indicates R1 likes to watch tv and sing. As either the television was not working or R1 was unable to operate the television independently, R1 was unable to engage in their choice activity. Based on interview and record review, the preponderance of evidence standard has been met, therefore, the allegation “staff violated resident’s personal rights” is deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency is cited (refer to LIC9099-D). Staff was informed that failure to correct to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of today’s report and appeal rights were provided.