The investigation revealed the following: In regards to the allegation that: "Staff are not following reporting requirements," it is alleged that the facility staff are not properly reporting an incident of a physical altercation that occurred on 09/08/2025 involving R1 and Resident #3 (R3) was reported by another resident to staff on 09/15/2025. LPA interviewed the Executive Director and Wellness Director denied the allegation stating that the facility reported the incident that occurred of the physical altercation between R1 and R3 on 09/08/2025 was reported to staff on 09/15/2025. Five (5) out of six (6) staff could not confirm nor deny the allegations since they were not aware nor witness that incident. LPA interviewed one (1) out of six (6) staff which stated that the incident of the physical altercation between R1 and R3 that occurred on 09/08/2025 was reported to the Health and Wellness Director on 09/08/2025. LPA also obtained facility Progress Notes dated 09/08/25 which indicate that the staff had knowledge of the physical altercation between R1 and R3 on 09/08/2025 as the incident was reported on the notes. LPA reviewed the Special Incident Report for the incident that occurred on 09/08/2025 which was not submitted by the facility to licensing until 09/18/2025 and not submitted within seven (7) days of the occurrence. There is enough evidence to substantiate.

Based on LPA's interviews conducted with the residents and staff, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 1 are being cited on the attached LIC 9099D.

The investigation revealed the following: In regards to the allegation that: “Staff did not safeguard client's personal belongings,” it is alleged that resident #2 (R2’s) couch was taken by staff while R2 was out of the facility at a skilled nursing facility (SNF) and that R2 received a replacement couch from the facility trash area. Wellness Director and one (1) out of six (6) staff interviewed denied the allegation stating that R2’s couch was never taken away or replaced. Executive Director interviewed could not confirm nor deny the allegation. Five (5) out of six (6) staff interviewed corroborated with the allegation stating that R2’s couch was replaced with a couch but could not specify where the prior couch went. One (1) out six (6) staff interviewed stated that the current couch in R2’s room was taken from the trash area. However, Executive Director, Wellness Director, and two (2) out of six (6) staff stated that the current couch in R2’s room was not from the trash area. Three (3) out of six (6) residents could not confirm nor deny that the current couch in R2’s room was from the trash area. LPA toured the facility with the Wellness Director and observed a couch in R2’s bedroom. However, LPA is unable to verify if R2’s couch in the room is the same couch while R2 was living at the facility prior to being transferred to the Skilled Nursing Facility due to conflicting statements obtained during staff interviews. Seven (7) out of seven (7) residents interviewed denied the allegation stating that their belongings are safeguarded and that staff have not taken any of their belongings from them without permission. LPA reviewed R2’s Resident Personal Property and Valuables form and it did not list a couch as part of R2’s property/valuables upon moving into the facility. Per Executive Director and Wellness Director, R2 was first admitted to the facility without any valuables except a bed and a TV. Per Executive Director and Wellness Director, the prior and current couch was given to R2 by the facility that belonged to a former resident that moved out of the facility. There is not enough evidence to substantiate.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.