Complaint Investigation Report

R1 reports feeling safe and is okay with sharing a room with R2. Interviews with R1 and R2 confirmed that the incident occurred in the middle of the night and do not believe anyone overheard the altercation. LPA interviewed Resident #3 (R3) who shares a common wall with R1 and R2. R3 reported that they did not overhear any altercation between R1 and R2. Records reviewed reported that Staff #1 (S1) was the only live-in staff onsite during the time of the incident. During a tour of the facility, LPA observed S1’s bedroom to be on the other side of the facility, away from any residents room. Interview with S1 reported that they did not overhear the altercation between R1 and R2. S1 further reported that staff are required to check on the residents (3) three times during the night. S1 reported doing their nightly rounds and did not observe anything out of the ordinary. The facility does not maintain a log of when nightly rounds are conducted. Records review conducted of R1 and R2’s needs and service plans do not address neither residents requiring 1:1 supervision. Records reviewed of the facility’s plan of operation do not report having wake staff during the nocturnal hours but do have live-in staff at the facility.

Information received alleged staff did not report incident to Community Care Licensing. Interview with S1 and R1 corroborated that the physical altercation between Resident #1 (R1) and Resident #2 (R2) was reported to S1 the following morning. Interview with S1 reported that they called Staff #2 (S2) to inform S2 of what R1 divulged to S1. S2 instructed S1 to ask R1 if they would like to file a police report to which R1 declined. Interviews with S2 confirmed S1’s account of the telephone call taken place. Interviews conducted with S1 and R1 confirmed that R1 refused to file a police report. A records review conducted of the facility’s incident reports received at Community Care Licensing confirmed an incident report was received on 6/4/2025 detailing an altercation between R1 and R2. The incident took place on 5/31/2025. Per Title 22, Reporting Requirements, the facility has within 7 days to report an incident which threatens the welfare, safety or health of any resident, caused by staff or by other residents.

Therefore, the allegation of due to lack of supervision, resident was in a physical altercation with another resident and staff did not report incident to appropriate agencies has been deemed unfounded. A finding that the allegation is unfounded meaning that the allegation was false, could not have happened, and/or is without a reasonable basis.

An exit interview was conducted, and a copy of this report was provided to staff, Roger Valenzuela.