Complaint Investigation Report

Review of R1’s facility records revealed that R1 had a history of agitation and did not like staff to redirect her by getting close to her. Interviews revealed that on June 6, 2023 during activities Staff 1 (S1) observed Staff 2 (S2) walking R1 backwards and sat R1 down on a chair roughly. Staff 3 (S3) also observed S2 treating R1 roughly because R1 was not listening to redirection from S2. Staff 4 (S4) also observed S2 walking R1 backwards aggressively. S1, S3 and S4 reported the incident to S5.

On June 8, 2023 S5 requested Staff 6 (S6) to complete a body check on R1 and S6 discovered a quarter size bruise on R1's upper right arm. S5 concluded that S2 did not apply any of the elder abuse training that was received during S2's hiring period and monthly training. S5 discovered two previous counseling within S2's four months of working at the facility. S5 was terminated on June 8, 2023.

The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has been met, therefore, the allegation is deemed substantiated. The following deficiencies are cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page.

An exit interview was conducted with Executive Director XX, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.