Complaint Investigation Report

Per the resident interviews, three (3) out of four (4) residents were corroborated with the allegation which resident#1 (R1) was consistently threatening to hit or had hit other residents. This situation had been going on for a year. Residents indicated other residents on the same floor with R1 would know what R1 did. LPA went to R1’s room and R1 opened the door. When LPA interviewed resident#1 (R1), the resident had the voice raised when talking to LPA at resident’s room door. Then, R1 used resident’s index finger pointing at LPA and raised voice to shout at LPA continuously. R1 moved closer to LPA with an index finger pointing at LPA’s face. R1 was about to hold a fist to LPA, LPA backed off quickly enough from being harmed and tried to de-escalate the situation. LPA thanked R1 and ended the intervi ew. R1 slammed the door close. Per staff interviews, Administrator was aware of R1’s combative behavior. Administrator handled R1 behavior by consulting psychiatrist and changing R1’s medication for 3 times . However, no other preventive action was taken. During the facility tour, LPA observed R1 walking in the hallway with a walker. R1 was combative and had aggressive behaviors toward other people on the hallway. Therefore, staff failed to ensure residents were safe from harm from other residents.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code.

An exit interview was conducted with Administrator. A copy of this report and appeal rights were provided.