Complaint Investigation Report

Review of R1’s facility records revealed that R1 had a history of agitation during incontinence care and refusing showers. Interviews revealed that in September 2022, R1 had an episode of incontinence and soiled their clothing. Staff 1 (S1) asked R1 to shower but R1 refused. S1 then took R1’s soiled pants and put them near R1’s face to show R1 that they needed to shower and R1 became upset and angry. Interviews revealed that S1 attempted get R1 to shower and R1 started yelling at S1 to “stop it” in response to being told to get in the shower. S1 was able to get R1 into the shower and began showering R1. Interviews revealed that while S1 showered R1, S1 grabbed R1’s left arm. R1 was observed with bruising in that area and reported pain after being grabbed. Interviews and record review revealed that on October 4, 2022, S1 indicated that R1 raised their arm to block S1 from spraying water on R1 and the shower-head cord wrapped around R1’s arm which caused R1’s bruising in that area. Interviews revealed that S1 was rude to residents and would yell and curse at residents when S1 was frustrated. Interviews revealed that the residents did not like the care provided by S1. The Department was unable to interview S1 due to S1 being unavailable.

The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has been met, therefore, these allegations are 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 Licensee Siera Navasak, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.