Complaint Investigation Report

According to interviews with both staff and the Administrator, the staff are not present when the residents are bathed by an outside agency. According to interview with S3, the believed that the aide caused the bruising but failed to report.

A record review of R1's hospital visit 10/28/25 in relation to the bruising, noted the bruising appeared to be in a grabbing pattern to R1's right and left upper extremities at distal biceps, bilateral shins, and upper chest, secondary to handling r1 for care. R1 was not on any medications that would cause bruising.

Observations of R1 detail they are bedbound and depend on caregivers for all activity's of daily living. R1 is nonverbal and its expression imposed difficulty on explaining how they sustained the injuries.

Based on the departments observations and interviews and record review which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted and appeal rights provided.

A copy of the report was read, was given to the administrator.