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32 | Additionally, it was revealed through interviews and record reviews that although Licensee was aware of the above, no evidence exists which demonstrated a concrete plan to address R1’s behavior towards other clients for purposes of providing a comfortable environment prior to filing of this complaint, or LPA’s initial complaint visit on 8-6-2025. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.
Allegation: Staff did not prevent a resident from threatening other residents. LPA conducted interviews and record reviews as noted above. Based on these interviews and record reviews, it was revealed that on multiple occasions, R1 engaged in verbalizations of threats towards other residents in care. Additionally, it was revealed through interviews and record reviews that although Licensee was aware of the above, no evidence exists which demonstrated a concrete plan to address R1’s threats towards other clients for purposes of providing a comfortable environment prior to filing of this complaint, or LPA’s initial complaint visit on 8-6-2025. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.
As a result of this investigation, citations are issued under Title 22, Division 6 and noted on LIC 9099D. An exit interview was conducted with Licensee and a copy of this report was provided. Appeal rights and LIC 811 provided. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
10/24/2025
Section Cited
CCR
80072(a)(2) | 1
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7 | 80072 Personal Rights. (a) …each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations….This requirement was not met as evidenced by: | 1
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7 | Licensee will develop and submit a plan to LPA outlining procedures on how to address residents’ behaviors towards other residents. Plan to be submitted to LPA by POC due date. |
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14 | Based on interview and record review, various residents in care experienced an uncomfortable environment due to another resident’s behavior which was not addressed concretely and effectively by Licensee. This posed a potential health, safety, and personal rights risk to residents in care. | 8
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Type B
10/24/2025
Section Cited
CCR
80072(a)(3) | 1
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7 | 80072 Personal Rights. (a) …each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat…This requirement was not met as evidenced by: | 1
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7 | Licensee will ensure the completion of staff training on personal rights of residents to include but not be limited to: Maintaining safe, healthful, and comfortable accommodations of residents and the right to be free from intimidation, ridicule, and threats. Proof of completed staff training to be submitted to LPA by POC due date.
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14 | Based on interviews and record reviews, R1 engaged in multiple instances of threatening other residents in care, and licensee did not concretely and adequately address known instances of R1 making these threats. This posed a potential health, safety, and personal rights risk to residents in care. | 8
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