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32 | Allegation: Staff yells at residents. It is alleged that DSP staff (S1) and staff (S4) yell at resident (R1). According to information obtained, S1 screams at residents (R1 & R2), and tells R1 to "shut up", and has been heard saying to R2 they are "nasty" because they smell. A total of four (4) residents were interviewed. All four residents stated S1 addressed R1 & R2 in an aggressive tone of voice and yells at the residents. Resident interviews revealed that S1 often used cuss words when like "f***, and other bad language when speaking to resident (R2). Residents stated that S1 yelled and mistreated residents (R1 & R2) when other staff were present, and that Licensee/Administrator was aware because they had addressed the yelling issue with S1. All four residents stated S1 yelled at all residents, but was primarily verbally abusive towards residents (R1 & R2). Residents stated staff (S4) also yelled at residents, and followed S1's work style. A total of five (5) staff were interviewed. Staff interviews revealed S1 has a loud tone of voice and yelled at residents (R1 & R2) in a mean manner. Staff (S1) acknowledged they have a loud voice. Staff (S1) stated they addressed residents in a "firm" voice when residents do not listen, and did yell loudly "stop" to residents R1 & R2. Staff (S4) denied the allegation, and stated that everyone knew co-worker/S1 spoke in a loud voice when the residents did not listen. Based on staff and resident interviews, it was revealed that S1 yelled at residents, and occasionally S4 also addressed residents in an inappropriate tone of voice, and neither used redirection techniques in order to mitigate resident behaviors. Both staff (S1 & S4) were suspended per Regional Center recommendation, and soon after both staff quit employment. There is sufficient evidence to substantiate the allegation.
Allegation: Staff make inappropriate comments towards resident. According to information obtained staff (S1) called resident (R1) fat and regularly commented to the resident they needed to lose weight. According to information obtained, S1 told R1 that if they did not exercise in the stationary bike staff would document it on a "book". A total of 5 staff were interviewed. None of the staff interviewed said they heard S1 call R1 fat, However, all staff confirmed that S1 made R1 use the exercise bike daily for approximately 30 minutes to 1 hour and would say to the resident they needed to lose weight. Staff (S1) denied calling R1 fat, but stated they did make the resident exercise everyday per physician's order. Licensee denied having knowledge of staff (S1's) inappropriate comments, but said staff (S1) had been asked in the past not to speak to residents in a loud voice. A total of four (4) residents were interviewed. All residents said staff (S1) spoke to resident (R1) in a mean way, called the resident "fat", and rushed the resident while eating. Resident interviews revealed that staff (S1) yelled often at R1 about exercising on the exercise bike. There is sufficient information to support the allegation. |
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32 | Allegation: Staff threatens resident. It is alleged DSP staff (S1) threatened resident (R1) by telling the resident that if they did not exercise they would not be able to participate in facility programming community outings and the resident would be reported to "ICE" immigration program. A total of five (5) staff were interviewed. Staff (S1) denied the allegation. Staff (S1) stated R1 was told to go to their bedroom to "rest" when the resident did not want to exercise; and did not allow R1 to be in the dining room area while S1 cooked meals, but the resident was allowed to sit in the living room. All staff interviewed denied ever hearing staff (S1) threaten R1 with calling immigrant if the resident did not follow staff (S1's) directions. All four (4) residents were interviewed. Resident (R1) said that S1 threatened to send the resident back to Mexico. Resident interviews revealed that S1 often threatened residents (R1 & R2). Residents confirmed S1 had threatening behavior because S1 raised their voice and sometimes banged on the counter and/or table when upset at the residents. Residents said that S1's actions caused all residents to be worried and sad. Based on interviews, there is sufficient supportive information to prove the allegation.
Allegation: Resident is not allowed to leave bedroom. The complaint alleges caregiver staff (S1) forced R1 to use the treadmill, wash dishes, take out the trash, wash their clothing, and if the resident refused S1 raised their hand as if to "hit" the resident. A total of 5 staff were interviewed. Staff (S1) stated the residents' chore is to throw the trash out. Staff interviews revealed that resident (R1) washed dishes and threw out the trash per staff (S1's) instruction. Administrator stated staff is responsible for washing dishes, throwing out the trash, washing resident's clothes, even if the resident's are capable of doing chores. The findings revealed that S1 had been told not to force R1 to exercise on the treadmill. Staff were aware that S1 "reminded" R1 to exercise and do chores and asked the resident to go to their room, but did not know the reason for sending the resident to their room. Resident (R1) stated that S1 yelled at the resident and sent the resident to their bedroom when S1 was cooking. Resident was also sent to their room whenever they exited their bedroom to use the restroom or was walking around the facility. Resident interviews revealed that S1 put R1 to wash the dishes, R2 to dry the dishes, but residents (R3 & R4) were not told to do chores. All residents stated that S1 made R1 do chores and yelled at the resident to stay in their bedroom. Based on record review, R1's Individual Program Plan (IPP) does not state R1 is to do household chores or stay in their bedroom. There is sufficient evidence to support the allegation. |
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32 | Allegation: Staff withheld resident's money. According to information obtained, staff (S1) was not giving resident (R1) the full personal & incidental (P & I) monthly allowance with the pretext of holding the money for the resident. It is also alleged that S1 did not allow resident (R1) to buy food at fast food restaurants during community outing to fast food restaurants and instead S1 packed two sandwiches for R1 because they are "fat". Information obtained states that on one occasion, S1 and S4 took all the residents to Wendy's fast food restaurant, but did not allow R1 to buy food with their personal & incidental (P & I) money, and staff proceeded to buy fast food for themselves. In addition, S1 allegedly took R1's P & I money to "hold" and did not disburse it to the resident. Staff interviews revealed that resident (R1) earns $20.00 per week from working at their day program. Staff handle R2's P & I money as well, and residents (R3 & R4) handle their own money. According to staff, the reason S1 did not allow R1 to buy food at Wendy's restaurant was because two weeks prior the resident had diarrhea and was told not to eat greasy food. However, resident interviews revealed that all four residents were taken to Wendy's restaurant on a Saturday outing, and S1 did not let residents (R1 & R2) buy fast food. Both residents ate bologne sandwiches packed by S1, while the other two residents and S1 & S4 ate fast food. Residents said that R1 cried and was sad. On 5/27/25, LPA reviewed R1's P & I records. Based on record review, it was observed that R1's P & I records stated the total was $197.53, and separate notebook of P & I states: $334.94, but on hand is $406.00. Resident (R1's) P & I total was short $126.47. There is sufficient evidence to corroborate the allegation.
Allegation: Staff are not treating resident(s) with dignity and respect. It is alleged that on May 22, 2025, staff (S1) verbally harassed resident (R1) after staff found out that R1 disclosed to day program staff the incident in which R1 was taken to Wendy's restaurant and not allowed to buy food, and instead S1 gave the R1 & R2 bologne sandwiches to eat while the rest ate the restaurant food. In addition, it was reported S1 asked day program staff how often R1 uses the restroom because allegedly the resident "always clogs the toilet", and the resident is "nasty and smells". All staff denied the allegation. Staff (S1) stated they have a loud high pitch voice and tone..."this is how I am." Staff stated residents are treated with respect. Licensee/Administrator stated S1's voice always sounded like they were mad, but may be misinterpreted. Three (3) out of the four (4) residents revealed that staff (S1) and sometimes staff (S4) treated R1 "bad" and yelled at R1 and R2 "a lot" and were "a little mean". There is sufficient information to support the allegation. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
03/20/2026
Section Cited
CCR
80072(a)(1) | 1
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7 | Personal Rights. Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met evidenced by: | 1
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7 | Administrator/Licensee agreed to:
1. Written Plan that states what was done to address staff verbal abuse towards residents.
2. Current in-service training in 80072 & 85072. |
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14 | Based on interviews the findings indicate S1 & S4 yelled at R1 & R2, and S1 made inappropriate comments to R1 about their weight i.e., called the resident "fat". Additionally, S1 harassed R1 and called them "nasty" and "smelly". This poses a potential health, safety or personal rights risk to persons in care. | 8
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Type B
03/20/2026
Section Cited
CCR
80072(a)(3) | 1
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7 | Personal Rights....To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. | 1
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7 | Administrator/Licensee agreed to:
1. Written Plan that states what was done to address staff verbal abuse towards residents.
2. Current in-service training in 80072 & 85072. |
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14 | Based on interviews, staff (S1) threatened and intimidated R1, which caused emotional distress to R1. This poses a potential health, safety or personal rights risk to persons in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
03/20/2026
Section Cited
CCR
80072(a)(7) | 1
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7 | Personal Rights. Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: Not to be locked in any room, building, or facility premises by day or night. This requirement was not met evidenced by: | 1
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7 | Administrator/Licensee agreed to conduct staff training in the following:
1. Personal Rights
2. Physician orders
3. Needs and Services Plan |
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14 | Based on interviews, the findings revealed S1 regularly sent R1 to their bedroom when the resident was not actively performing chores or using exercise equipment. This poses a potential health, safety or personal rights risk to persons in care. | 8
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Type B
03/20/2026
Section Cited
CCR
80026(b) | 1
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7 | Safeguards for Cash Resources, Personal Property, and Valuables of Residents. If such a client is accepted for or maintained in care, his/her cash resources, personal property, and valuables...... shall be handled by the licensee or facility staff, and shall be safeguarded in accordance with the requirements specified in (c) through (n) below. This requirement was not met evidenced by:
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7 | Administrator agreed to submit:
1.Proof that R1's missing P & I money ($126.47) was reimbursed.
2. Submit money handling policy
3. Proof of staff training |
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14 | Based on record review and interviews, S1 withheld R1 and R2's P & I money during an outing to a fast food restaurant. Additionally, on 5/27/25 LPA reviewed R1's P & I money records and observed inaccurate records. R1 was missing $126.47 in P & I money. This poses a potential health, safety or personal rights risk to persons in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
03/20/2026
Section Cited
CCR
80065(l) | 1
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7 | Personnel Requirements. Personnel shall provide for the care and safety of persons without physical or verbal abuse, exploitation or prejudice.
This requirement was not met evidenced by: | 1
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7 | Administrator shall conduct staff training on regulation 80065, verbal abuse, and mandated reporting. In addition, submit a written plan that address staff misconduct and consequences. |
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14 | Based on interviews, the findings revealed that staff (S1's) verbal abuse towards R1 caused the resident anxiety, stress, and angst when returning home from day program. This poses a potential health, safety or personal rights risk to persons in care. | 8
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