Complaint Investigation Report

Regarding the allegation: Staff handle resident roughly causing injury. On 01/20/2026, it was alleged that Individual #1 (I1) handled Resident #1 (R1) in a rough manner causing bruising on R1’s arm. Record review revealed that R1 requires full assistance for bathing, dressing, transferring and toileting. Interviews with R1 revealed that Individual #1 handled R1 in a rough manner when assisting R1 with getting out of bed. R1 described how I1 handled R1’s arm in an aggressive manner and squeezed R1’s arm causing R1’s arm to bruise. During the course of the investigation, the LPA was provided with pictures of R1’s bruised arm. Interviews with the ED at the time, revealed that I1 was not staff and instead was a staffing agency staff that only worked for a few days, no exact dates were provided. Interviews with staff revealed no witnesses to the incident involving I1 handling R1 in a rough manner, however staff stated that R1 is alert and can verbalize when issues arise. Based on interviews, the preponderance of evidence standard has been met, therefore the above allegation, “Staff handle resident roughly causing injury” is deemed Substantiated at this time.

2.) Staff do not treat resident with dignity or respect. It was alleged that Staff #1 (S1) told R1 that if R1 were to walk away and fall, that S1 will not help R1. When interviewed on two separate dates, R1 revealed consistent statements and descriptions of the interaction between R1 and S1. Interviews with R1 revealed that in January 2026, R1 was trying to get out of bed and S1 told R1 if R1 does not listen to S1 and if R1 walks away and falls that S1 is not going to help R1. R1 did fall on 01/08/2026 and was sent to the hospital, no fractures were noted. However, R1 discharge diagnosis was listed as sacral contusion and left hip pain. Interviews with S1 denied the allegation. Interviews with staff and R1 revealed that S1 is no longer assigned to assist R1. R1 stated that R1 does not want S1 to assist with their care needs. Based on interviews, the preponderance of evidence standard has been met, therefore the above allegation, “Staff do not treat resident with dignity or respect.” is deemed Substantiated at this time.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D). Civil Penalties issued for the total amount of $500. The Interim ED was informed that failure to correct deficiencies may result in additional civil penalties.

Exit interview conducted with Interim Executive Director (ED) Stephani Smith. A copy of the report and appeal rights were provided.