Complaint Investigation Report

It was alleged that staff speak to residents in an inappropriate manner and staff does not treat residents with dignity or respect. On 08/01/2024, the Department received two (2) self-reported incident reports regarding two (2) staff members who no longer work at the facility as they were suspended on 07/31/2024. The incident reports stated that on 07/06/2024, two staff members were assisting a resident when Staff #1 (S1) slapped the resident. Staff #2 (S2) witnessed the incident and recognized it as abuse, but informed the Administrator later on 07/31/2024 due to fears of retaliation from S1 and Staff #3 (S3), the relative of S1. The Department received the SOC341 for this incident on 08/02/2024. The second incident report stated that on 07/12/2024 and 07/22/2024, S3 was verbally abusive to Resident #1 (R1). On 07/12/2024, R1 asked S3 for a cleaning. R1 requires a two (2) person assist and said they did not feel comfortable with S3 performing the cleaning solo, however, S3 was insistent. R1 refused the cleaning due to S3’s verbal abuse during the exchange and the potential dangers of the solo clean. On 07/22/2024 after changing the sheets on R1’s bed, R1 asked S1 and S3 to shift the bed. S1 and S3 began trying to shift the bed without unlocking the wheels and when R1 stated that the wheels need to be unlocked, S1 raised their fists at R1 asking if the resident wanted to fight them and both S1 and S3 became verbally abusive. LPAs Barutyan and Chochian as well as Brian Balisi and Trevor Byrne conducted separate case management visits for the incidents on 08/02/2024. LPAs Barutyan and Chochian interviewed the Administrators who stated that they were not aware of how S1 and S3 were treating the residents as S2 and S4 were afraid to report the abuse. LPA interviewed R1 on 08/02/2024 who stated that they felt “unsafe” and that the staff had a “hostile” relationship with R1. LPA interviewed R1 on 08/14/2024 who stated that they have “not experienced any mistreatment since the two staff left” and that they are “treated well here compared to other places [they have] stayed at and heard about.” LPA interviewed S4 on 08/02/2024 who stated that they have “had to tell [S3] to ‘calm down’ many times when [S3] is handling [R1] because [S3] gets verbally aggressive” and that “S1 and S3 have both said that they ‘wish the residents were dead.’" LPA was unable to interview S2 as they are taking a leave of absence for personal reasons. Based on incident reports submitted to the Department and interviews conducted, the allegations “Staff speaks to resident in an inappropriate manner” and “Staff does not treat resident with dignity or respect” are deemed SUBSTANTIATED at this time.

The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was informed that failure to correct the deficiency may result in civil penalties.

Exit interview conducted. Appeal rights and a copy of the report was provided.