LPA interviewed three (3) staff and all three (3) denied the allegation. LPA interviewed nine (9) residents and all nine (9) where not able to corroborate the allegation. Based on interviews with staff, one (1) staff member was making rounds by R1 and R2 room on 03/12/2026 at around 4:30 pm and heard R2 in distress, Staff entered the room and saw R1 holding a hollow metal bar, that belongs on the outer part of the bathroom sink. Staff immediately removed the metal bar from R1 and separated the residents. R2 confirmed R2 was struck on her buttocks. R1 told staff that R1 thought that R2 had stolen R1 money and that is why R1 attacked R2. Police were called and R1 was detained until Los Angeles County Psychiatric team arrived and R1 was transported via ambulance and placed on 5150 hold. R1 remains on hold to date. R2 was assessed and did not suffer any injuries. R2 confirmed this. On 02/03/2026, R1 hit another resident and then returned to facility. On 02/12/2026, facility completed an updated Individualized Service Plan to address R1 behavioral issues that included extra wellness checks every two (2) hours. R1 medication was adjusted by R1 doctor. After this incident on 03/12/2026, facility can no longer accommodate higher level of care for R1 and is working with Telecare representative to find appropriate placement. The two (2) residents that were assaulted on different dates by R1 both stated that it was not due to lack of care and supervision of staff. Both stated they feel safe at facility. R1 stated that the staff does provide care and supervision to the residents.

Based on statements and interviews conducted with staff and residents and record review, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided.