Complaint Investigation Report
On February 5, 2026, residents (R1, R2, and R3) were taken on an outing to the Cheesecake Factory and were accompanied by staff (S4, S5, and S6). Interviews with S4 and S5 indicated that R1 was served mashed potatoes. Interviews indicated that S5 was assisting R1 with their mealtime ensuring that any chunky bits of potatoes were removed and that the potatoes were mashed again prior to R1 eating. Interviews indicated that R1 experienced a brief coughing episode. However, R1 was not choking and there were no signs of respiratory distress observed following. R1's physician's orders indicated that they are to eat a pureed diet, which S4 and S5 indicated they were following on the outing. Upon return from the outing, a nurse on duty at the care home assessed R1. According to R1's Nurses Notes, R1's lungs sounded clear and there were no signs or symptoms of aspiration noted. Notes indicated that respirations were even and unlabored, vital signs were within normal limits, and no concerns were noted. R1 was not sent to the hospital following the outing and was sent to the hospital for a separate health condition on February 21, 2026.
Interviews with staff (S1, S2, and S3), S4, and S5 indicated that they have never witnessed staff handling residents in a rough manner. Interviews also indicated that staff handle residents carefully. Interviews with R1's responsible parties indicated that they have never witnessed staff handling residents roughly. They indicated that they visit the facility weekly and that the facility staff provide outstanding care. Interview with resident (R2) indicated that they are doing good, staff treat them well, and all their care needs are being met.
Based on documentation obtained and interviews conducted, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED.
No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction