Complaint Investigation Report

Allegation: Facility staff verbally assaulted resident in care.

It was alleged that facility staff verbally assaulted resident in care. Based on interviews conducted, it was determined that on 10/08/2025, Resident 1 (R1) was found in the backyard of the facility early in the morning, sleeping with a guest. Staff member 2 (S2) approached R1 and woke them up. When R1 asked if they were in trouble, S2 reassured them that they were not and allowed them to continue sleeping. Between approximately 7:00 a.m. and 7:30 a.m., both Staff Member 1 (S1) and S2 approached R1 and the guest again, instructing them to leave the premises. According to further interviews, S1 became verbally aggressive when R1 stated they had been told they could remain. S1 responded by saying, “Nah, you can get the f*** out of my house too because you are not following my rules.” Additionally, it was reported that S1 continued to threaten R1 in the front yard, stating they would have their partner come and physically harm the resident if they did not leave. Witnesses indicated that shortly after this incident, bystanders intervened, and S1 left the premises in their vehicle. Based on the interviews conducted, facility staff verbally assaulted resident in care.

Allegation: Facility staff physically assaulted resident in care.

It was alleged that facility staff physically assaulted resident in care. Based on interviews conducted, it was determined that on 10/08/2025, Resident 1 (R1) was found in the facility's backyard early in the morning, where they were approached by Staff 1 (S1) and Staff 2 (S2). Witnesses stated that during the encounter, S1 became verbally aggressive toward R1 and their guest. In response, R1 stood up holding their phone. At that point, S1 struck R1’s wrist and knocked the phone from their hand. Witnesses confirmed observing S1 hit R1’s wrist during the incident. Based on interviews conducted, facility staff physically assaulted resident in care.

Based on the information gathered, it was concluded that facility staff engaged in physical assault against a resident under their care.

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

An exit interview was conducted and a copy of this report and appeals rights was provided to the facility at the end of this visit.