Complaint Investigation Report

According to interviews with six staff members, staff denied observing R2 entering R1's room. According to staff interviews, staff are constantly with residents or have eyes on the residents. The only time staff are not with a resident is when the resident is in the shower or request privacy in their room. While residents are in the shower or in the bedroom, staff will outside the door. One interview with staff revealed that there were a few times when the hallway was left unsupervised for up to 15 minutes. However, there is no indication of when the event occurred to determine that there was no staff supervision at the time of the incident. Depending on the resident, staff to resident ratio varies. Based on an outside agency interview/personal observation, the outside agency felt the level of staff supervision was appropriate.

An Investigation conducted by the Long Term Care Ombudsman determined it was not a criminal matter. Records review obtained from The Sacramento County Sheriff Office did not pure the complaint and closed the case.

Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated.

Per California Code of Regulations (CCRs) - Title 22, no deficiencies cited.

An exit interview was held, and a copy of report was left at the facility.