Complaint Investigation Report, 11/22/2022 — Royal Oaks Home Care, Simi Valley CA

Regarding the allegations that staff caused a resident (R1) to fall, staff physically restrained resident, and staff prevented resident from leaving the facility, the complainant’s concern was that inappropriate behavior by staff, which included physically restraining R1 in an effort to prevent them from exiting the facility, caused R1 to fall.

During the interviews conducted on 7/21/2022, S1 stated that on 7/7/2022, R1 attempted to elope from the facility through the garage as R1 wanted additional cigarettes and to return home. S1 stated they prevented R1 from leaving the facility by blocking R1, but S1 insisted to the LPA they did not put their hands on R1. S1 stated they were holding a plate of food at the time and R1 slapped the plate of food out of S1’s hand. S1 stated that the action of hitting the plate caused R1 to lose their balance and fall back into some boxes in the garage. During LPA’s interview with R1, they gave substantively the same statement.

However, during the LPA’s interviews with witnesses and review of police records, it was found that R1 and S1 gave different statements to the police. On 7/7/2022, S1 told the police that they grabbed R1’s wrists to prevent R1 from leaving the facility. While holding R1’s wrists, S1 walked R1 backward into the garage but R1 lost their balance and fell. R1’s statement to the police on 7/7/2022 indicated S1 grabbed R1 by the shoulder and pushed r1 down. The police did not find any evidence of assault, but they did indicate to the administrator the staff should have a hands-off approach to addressing R1’s elopement attempts.

Although the above noted allegations were found unsubstantiated during the initial complaint visit on 7/21/2022, after further review of documents and additional witness interviews, the above noted allegations are deemed SUBSTANTIATED at this time.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted. Today's report and appeal rights were discussed and emailed.