Complaint Investigation Report

LPA investigated the allegation, “Staff do not treat residents with dignity and respect.” Based on interviews conducted it was indicated that multiple staff would tell R1 they would use the hoyer lift to get R1 out of bed, knowingly R1 is afraid of the lift. Interviews revealed staff suggest the use of the hoyer lift as a motivational tool to get R1 out of bed. Interviews indicated that staff would yell at R1 when he did not want to get out of bed in the mornings, which negatively impacts resident's sense of well-being.

LPA investigated the allegation, “Staff are not providing residents with adequate hand washing supplies.” During visit conducted on April 8, 2025, LPA observed two of two facility bathrooms did not have paper towels and soap. Staff stated they would provide paper towels for both bathrooms during LPA’s inspection. Additionally, during visit conducted on April 17, 2025, LPA observed both bathrooms still did not have paper towels. As a result of LPA’s visits on April 8, 2025, and April 17, 2025, LPA determined that the facility was not providing adequate hand washing supplies. Interviews also indicated the facility had been running out of hand soap on multiple occasions.

Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations, Title 22, and the California Health and Safety Code are cited on the attached LIC9099-D.

An exit interview was conducted, and a copy of the report and appeal rights were provided.