During today's visit LPA and ED briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations. LPA obtained copies of pertinent documents relevant to the investigation.

On the allegation, Staff caused injury to resident, it is the concern of the Reporting Party (RP) that S1 caused an injury / skin tear to R1. To investigate this complaint, LPA conducted in person interviews, file and record review and obtained copies of pertinent documentation relevant to the investigation.

Interview with S1 revealed that on 05/23/26 at approximately 10:00 a.m., R1 came to the medication room requesting their medication, although they had already received their medication for the day. S1 informed R1 that their medication had already been administered and redirected R1 outside before continuing with their duties. However, R1 was persistent and returned multiple times. S1 stated this occurred approximately three times, with R1 repeatedly returning to the medication room requesting their medication, and S1 redirecting them each time. S1 reported that the med room door was slightly open and R1 was standing at the doorway. S1 stated, “R1 is persistent and at times difficult to redirect.” During R1’s third return, R1 attempted to insert their key into the medication room door lock. S1 stated that they “pulled the lanyard, slightly scraping the resident and leaving a red mark; there was a tiny skin break and a small skin tear.” S1 further stated, “It was a tiny red mark; the skin was slightly broken.” S1 observed two tiny holes and provided first aid to R1.

Based on information gathered during the course of the investigation, and interviews there is sufficient evidence to support the allegation occurred. Therefore, the allegation of Staff caused injury to resident, is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiency may result in civil penalties. The Executive Director (ED) departed at 4:23 p.m. and designated the Business Office Director (BOD) to sign the report on their behalf. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.