Complaint Investigation Report

The Physician’s Report for C1 dated January 6, 2026, indicates that C1 is non-ambulatory, requires assistance with transferring, and is able to communicate needs. The Needs & Service Plan dated November 1, 2025, reports that C1 walks with an unsteady gait, is at risk of falls, and uses a walker but has a difficult time maneuvering it. Two out of three clients interviewed denied the allegation. LPAs were unable to take statements for two clients due to their medical condition and others were out of the facility during the visit. One client initially confirmed the allegation and later denied the same allegation during the interview. Four out of five staff denied the allegation, stating staff do not force clients to exercise if they do not want to. During an interview, S1 confirmed the allegation by admitting they continue to have C1 take 2-3 steps after C1 communicates they do not want to continue trying to walk.

Based on interviews that were conducted and records reviewed during the investigation, the preponderance of evidence standard has been met for allegation: Facility is forcing client to participate in exercise is deemed SUBSTANTIATED. A deficiency is being cited on the attached LIC 9099-D, as per Title 22, Division 6, Chapter of the California Code of Regulations.

An exit interview was conducted with Administrator Victoria Valencia and a copy of this report, LIC9099-D, LIC811, and appeal rights were provided at the end of the visit.