Point Loma Elder Care

Allegation investigated: Licensee neglect resulted in hospitalization. Licensee neglect resulted in delayed medical care. Licensee did not report resident's change in condition.

Licensing Program Analyst (LPA)Janet Ngallo conducted a telephone visit to deliver findings regarding the above mentioned complaint allegations due to the facility being closed. LPA identified herself and discussed the purpose of the call with the Licensee Nikki Mundhada. On 02/24/2025, it was alleged that licensee neglect resulted in the hospitalization of a resident (R1), licensee neglect resulted in delayed medical care for R1, and that the licensee did not report R1's change in condition. The Department's investigation consisted of interviews with internal and external sources and reviewed multiple facility records as well as outside medical documentation. [Cont. on LIC 9099-C] Unsubstantiated [Cont. from LIC 9099] Regarding the allegation that licensee neglect resulted in the hospitalization of R1, interviews revealed that R1 was first checked on by S1 at approximately 0430 hours on 02/01/2025 and was awake without reporting abdominal pain. At approximately 0655 hours, S1 checked on R1 again, at which time R1 reported abdominal discomfort. S1 notified S2, who instructed S1 to administer Tylenol. When S1 returned at approximately 0813 hours to assist R1 with breakfast, R1 reported that the pain had worsened. S1 contacted emergency services, and paramedics arrived shortly thereafter. R1 was transported to a medical center, where R1 was diagnosed with Ogilvie’s syndrome, a rare condition that can develop rapidly and is difficult to detect without imaging unless a patient reports pain. Interviews and bowel movement logs indicated that R1 had been having regular bowel movements and had not reported abdominal pain prior to 02/01/2025. Records confirmed that R1 denied abdominal pain or distention prior to hospitalization. Regarding the allegation that licensee neglect resulted in delayed medical care for R1, interviews and records reviewed showed that R1 had not complained of abdominal pain prior to 02/01/2025 and was having documented, regular bowel movements. Staff reported that R1 was not exhibiting nausea, vomiting, or other signs of distress until the morning of 02/01/2025. When R1 first reported abdominal discomfort at approximately 0655 hours, S1 contacted S2 and administered Tylenol as instructed. When R1 later reported worsening pain at approximately 0813 hours, S1 contacted emergency services immediately. Paramedics responded within minutes and transported R1 to the hospital for evaluation. Medical professionals reported that Ogilvie’s syndrome can occur rapidly and without early warning signs, and that the condition would not have been identifiable without imaging unless the resident expressed pain. Regarding the allegation that the licensee did not report R1’s change in condition, interviews and records support that R1 did not exhibit any change in condition prior to 02/01/2025. Staff reported no signs of distress, confusion, or discomfort beyond R1’s baseline, and interviews consistently indicated that R1 did not experience or report abdominal pain until the morning of 02/01/2025. Records review of R1’s bowel movement log confirmed normal bowel activity with no noted abnormalities or interruptions in routine, including documented movements on 01/31/2025. Facility charting reflected no concerns or reported changes in condition leading up to the incident. Once R1 stated experiencing abdominal pain at 0655 hours, staff notified supervisory personnel, and when symptoms escalated at 0813 hours, staff immediately contacted emergency medical services. [Cont. on LIC 9099-C pg. 1] [Cont. from LIC 9099-C] Based on interviews conducted, review of records, including outside sources records, a preponderance of evidence does not exist to support the allegation. Therefore, the allegation is unsubstantiated. An exit interview was conducted via telephone with Licensee Nikki Mundhada. A copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided and documents were delivered via email.the state’s words, verbatim · CDSS document, Aug 27, 2026 · control 08-AS-20250224165115

Allegation investigated: Staff hit a resident

Licensing Program Analyst (LPA)Tiffany Holmes contacted the facility to deliver findings for a complaint investigation via tele-virtual. LPA identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Gaurav Rathi, Administrator. Previous LPA conducted interviews with residents, staff, and outside sources, made observations, and obtained and reviewed pertinent records. LPA conducted the initial visit on April 14, 2025. It was alleged that staff hit a resident. Interviews revealed that the complaint came in 2025 stating that Resident (R1) was hit by a staff one to two years prior. Interviews revealed they were not able to provide a specific date of when this incident occurred, nor the name of the staff member who alledgedly hit the resident. Interviews with an outside source revealed that they did not recieve any complaints about a staff hitting the resident. Interviews with an outside source revealed there was a problematic staff that was transferred to another facility but it was not for hitting any residents. Interviews also revealed that the resident in question is no longer at the facility and could not be interviewed. The Department has investigated the above-mentioned allegation and based on interviews, LPA observations, and records review, it was determined that the complaint allegations are unsubstantiated. The allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred An exit interview was conducted with Adminsitrator Gaurav Rathi, via face time and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided via email. An electronic email read receipt confirms the documents were received. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 8, 2026 · control 08-AS-20250404145556

Allegation investigated: Physical abuse resulting in serious bodily injury. Staff did not safeguard resident's personal items.

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced subsequent visit to deliver findings regarding the above‑mentioned allegations. LPA identified themselves and met with Administrator Nikki Mundhada, to discuss the purpose of the visit and elements of the complaint. On 11/12/2025, it was alleged that physical abuse towards a resident resulted in serious bodily injury and that staff did not safeguard resident's personal items. The Department’s investigation consisted of interviews with facility staff, residents, and a review of facility records. (Cont. on LIC 9099-C) Unsubstantiated (Cont. from LIC 9099) Staff interviews did not corroborate the allegations as staff consistently stated that they have not witnessed any physical abuse toward R1 or any other resident, nor have they stolen any personal property belonging to R1. Staff reported that when R1 moved into the facility, they brought a significant amount of belongings that obstructed fire exits. The social worker was notified, and the facility issued several written notices to R1 regarding removal of excess items. The facility also contacted a junk removal service to address the blockage of fire exits. Staff stated that these actions were taken to maintain safety and compliance with fire regulations. Staff reported that R1 has a diagnosis of dementia and has a history of making statements that are inconsistent or unrelated to actual events. Residents interviewed stated they had not observed any concerning interactions between staff and residents, and that they feel safe and comfortable. Review of the facility records did not corroborate the allegations as records indicated that R1 has a history of making allegations about physical abuse. R1’s Needs and Services Plan lists their primary diagnoses of vascular dementia with delusions, medical non-compliance, chronic low back pain, and a history or frequent falls. The plan notes that R1 prefers to stay in their room and has a pattern of reporting that someone enters their room and beats them, despite no corroborating evidence. R1's Needs and Services Plan stated that R1 previously reported that caregivers at their former facility beat them with a stick, and that they have since made similar allegations about staff at the current facility. R1’s social worker and primary care provider are aware of these ongoing behavioral patterns and statements. R1's personal property and valuables document revealed 4 (four) property items listed and noted to be located in the resident's room. Email correspondence revealed written notices given to R1 regarding removal of their belongings, and confirmation of R1's payment for removal of the excess belongings. LPA observed R1 in their room. R1 endorsed pain in the left lower back but no visible bruising, swelling, redness, or injury was observed. R1 demonstrated confusion during the interaction and made statements about wanting to return to their home town. R1 stated that they were hit by staff once, but cannot recall the name of the person or the time that it happened. R1 stated that they currently feel safe at this facility. LPA observed staff interacting appropriately with residents during the visit. No signs of neglect, mistreatment, or unsafe conditions were observed. R1’s room and surrounding areas appeared clean, orderly, and free of hazards. Personal property listed in R1's possession were present in R1's room. (Cont. on LIC 9099-C pg. 1) (Cont. from LIC 9099-C) Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred. Therefore, the allegations are determined to be UNSUBSTANTIATED. An exit interview was conducted with Administrator Nikki Mundhada, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided and their signature confirms receipt of the report.the state’s words, verbatim · CDSS document, Feb 10, 2026 · control 08-AS-20251112192046

Allegation investigated: Staff physically abused resident.

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced visit to initiate a complaint investigation and deliver findings regarding the above mentioned allegation. LPA identified themselves and met with Facility Manager Vinny Rathi, to discuss the purpose of the visit and elements of the complaint. On 01/06/2026, it was alleged that staff physically abused Resident 1 (R1). The Department’s investigation consisted of an unannounced facility visit, interviews with facility staff, residents, and a review of facility records. (Cont. on LIC 9099-C) Unsubstantiated (Cont. from LIC 9099) Staff interviews did not corroborate the allegation as staff consistently stated that they have not witnessed any physical abuse toward R1 or any other resident. Staff reported that R1 has a diagnosis of dementia, often expresses a desire to return to their hometown, and has a history of making statements that are inconsistent or unrelated to actual events. Residents interviewed stated they had not observed any concerning interactions between staff and residents, and that they feel safe and comfortable. Review of the facility records did not corroborate the allegations as records indicated that R1 has a history of making allegations about physical abuse. R1’s Needs and Services Plan lists primary diagnoses of vascular dementia with delusions, medical non-compliance, chronic low back pain, and a history of frequent falls. The plan notes that R1 prefers to stay in their room and has a pattern of reporting that someone enters their room and beats them, despite no corroborating evidence. R1’s past Needs and Services Plans documented that R1 is fixated on the idea of moving to the East Coast and living independently. It also stated that R1 previously reported that caregivers at their former facility beat them with a stick, and that they have since made similar allegations about staff at the current facility. R1’s social worker and primary care provider are aware of these ongoing behavioral patterns and statements. LPA observed R1 in their room. R1 endorsed pain in the left lower back but no visible bruising, swelling, redness, or injury was observed. R1 demonstrated confusion during the interaction and made statements about wanting to return to Virginia. R1 stated that they were hit by staff once, but cannot recall the name of the person or the time that it happened. R1 stated that they currently feel safe at this facility. LPA observed staff interacting appropriately with residents during the visit. No signs of neglect, mistreatment, or unsafe conditions were observed. R1’s room and surrounding areas appeared clean, orderly, and free of hazards. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred. Therefore, the allegation is determined to be UNSUBSTANTIATED. An exit interview was conducted with Facility Manager Vinny Rathi, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided and their signature confirms receipt of the report.the state’s words, verbatim · CDSS document, Jan 13, 2026 · control 08-AS-20260106165520

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Facility Manager Vinit Rathi. Administrator Niki Mudhada arrived shortly after. According to the facility’s license, the facility has a maximum capacity of six residents, of whom all may be non-ambulatory and 1 may be bedridden. LPA toured the interior and exterior of the facility and inspected each room. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. There was one broken window in the living room that was actively being replaced. One bathroom was in the middle of being fixed and facility had reported such to LPA via incident report. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Water was measured at 107 degrees F. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents. Medications were labeled, as required, and stored in locked cabinet. No pool or body of water present. Per Niki no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher was present and purchased within the last year. First aid kit was complete and readily accessible. Resident records reviewed had required documentation. Staff records reviewed contained required documentation. No deficiencies were issued on today's visit. . An exit interview was conducted with Administrator Nikita Mudhada, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided to during the visitthe state’s words, verbatim · CDSS document, Oct 8, 2025

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced quarterly Case Management/Legal Non-Compliance visit. LPA was granted entry by and disclosed the purpose of the visit to Administrator Nikita Mundhada. On January 22, 2025, the Licensee agreed on a compliance plan for the following 24 months through January of 2027. During today’s visit, LPA conducted a general overall inspection of the facility, interviewed staff, reviewed records, and evaluated licensee’s ongoing compliance with the requirements described in the LIC9111. During the visit, the facility was clean, safe, and in good repair. Records reviewed were current and complete. There were no immediate health or safety concerns. Based upon today’s observation and interviews, the facility was operating consistent with the terms of the compliance conference. No deficiencies were observed or issued as part of this compliance visit. An exit interview was conducted with Administrator Nikita Mundhada, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Oct 8, 2025

Allegation investigated: Neglect/lack of supervision resulted in resident being abused

Licensing Program Analysts (LPA) Iby Strong and Janet Ngallo conducted an unannounced complaint visit to initiate an investigation on the above-mentioned allegation. LPAs met Caregiver Hugo Duran and discussed the purpose of the visit. Co Administrator Vinit Rathi and Administrator Nikita Mundhada arrived shortly after. On August 21, 2025, Community Care Licensing (CCL) received a complaint alleging Resident 1 was abused. During the investigation, LPA Strong and LPA Ngallo conducted interviews, and reviewed facility records. According to the allegation on an undisclosed date, R1 was abused, there was no information provided on the type of abuse or a name for the suspected abuser. Records collected revealed that R1 has a diagnosis of a major neurocognitive disorder with behavioral disturbances and agitation towards staff. Unsubstantiated During an interview with R1, R1 referenced past abuse from childhood, unrelated to the facility. Interview with multiple staff revealed that R1 has moments of agitation and will make statements about fearing staff. Interview with an outside source, established that R1 does have a history of referencing past childhood trauma but outside source has no reason to believe R1 is or was in any health or safety threat while in care of the facility. Records collected also revealed that Administrator was continuously communicating behaviors to R1's primary care provider. Based on interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Administrator Nikita Mudhda, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 26, 2025 · control 08-AS-20250821134711

Allegation investigated: Staff did not assist resident with dental care Staff did not assist resident with dressing

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced follow up complaint investigation visit and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Administrator Gaurav Rathi. Throughout the investigation, the Department secured records and conducted interviews with external and internal sources, including staff and residents. It was alleged staff did not assist a resident with dental care. On January 17th, 2025, it was reported to the Department staff did not assist Resident # 1 (R1) with cleaning R1’s dental implants, as indicated by R1’s dentist. Review of records revealed R1’s implants needed to be cleaned daily and set in water when not in use. Interviews with internal sources confirmed staff would clean and set R1’s implants in water when not in use. Staff would remind R1 to place and remove the dental implants. (See LIC 9099-C for continuation of report.) Unsubstantiated It was not common, but when R1 was not able to place them, or remove them, staff would manually assist R1. There were a few occasions when R1 refused to place or remove the implants. These sources did not have any concerns with lack of assistance with cleaning, and there was no recollection of staff forgetting to clean the dental implants. As part of the facility's protocol, staff were tasked with photographing R1's dental implants placed in a container with water. These photographs were shared with the LPA. An interview with an external source, who frequently visited the facility, revealed staff were assisting R1 with cleaning and maintaining R1’s dental implants. R1 mentioned to this source staff may have forgotten on one occasion to assist R1 with cleaning R1’s dental implants. This source added R1 seemed to be confused more than usual when this statement was made. The LPA interviewed R1, who was observed to be oriented to person, and place. R1 recalled previously residing at the facility and staff may have not cleaned R1’s dental implants on one occasion. R1 did not have any concerns with R1’s dental implants not being cleaned regularly. Based on the evidenced obtained, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. It was alleged staff did not assist a resident with dressing. On January 17th, 2025, it was reported R1 was witnessed to be wearing a dirty shirt to a medical appointment. Interviews with internal sources and a review of records revealed R1 was diagnosed with Parkinson’s disease, tremors, and Mild Cognitive Impairment. Due to R1’s tremors, R1 may spill, or drool on R1’s shirt. Staff would assist R1 when R1’s shirt became dirty. One source reported R1 liked to snack on chocolate and R1 would sometimes hold the chocolate in R1’s mouth. R1 may have had a clean shirt prior to leaving the facility, drooled during the transport to the medical appointment, which may have resulted in R1 having a dirty shirt. An interview with an external source, who frequently visited the facility, revealed R1 had plenty of clothing, but R1 could be selective. Some of R1’s shirts were described as “raggedy”. The LPA conducted a collateral visit to interview and observe R1’s clothing. R1 did not report any concerns with not being assisted with dressing. The LPA attempted to observe R1 clothing, but R1 had recently moved in to this placement and did not bring any of R1’s clothing. Based on the evidence obtained, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. (See the additional LIC 9099-C for continuation of report.) An exit interview was conducted with Administrator Gaurav Rathi, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were providedthe state’s words, verbatim · CDSS document, May 23, 2025 · control 08-AS-20250117155139

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management visit. The LPA introduced himself and disclosed the purpose of the visit to Administrator Gaurav Rathi. During the visit, the LPA conducted a tour of the facility, obtained Plan of Correction (POC) documents, and secured signatures for documents. There were not immediate health or safety concerns observed by the LPA. An exit interview was conducted with Administrator Gaurav Rathi, to whom a copy of this report, and Licensee Rights (LIC 9058), were provided via email. An email read receipt confirms the documents were received by the administrator.the state’s words, verbatim · CDSS document, Jan 21, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management visit. The LPA introduced himself and disclosed the purpose of the visit to Caregiver Hugo Duran. Administrator Gaurav Rathi arrived during the visit and assisted the LPA. During the visit, the LPA conducted a tour of the facility, secured report signatures, and delivered amended reports. The LPA also requested training records for staff. An exit interview was conducted with Rathi, to whom a copy of this report, and the Licensee Appeal Rights (LIC 9058), were providedthe state’s words, verbatim · CDSS document, Oct 25, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Hugo Perez. Licensee Gaurav Rathi and Administrator Travonna Washington arrived during the visit and assisted the LPA. The facility was licensed for a capacity of six (6) non-ambulatory residents, of which one (1) could be bedridden in room #4. The facility was also approved for hospice waiver for three (3) residents. The LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, and stored in a locked area. No pools or bodies of water on the premises. Per staff, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and reviewed multiple staff and client records/files. The files which LPA reviewed contained required documents. No deficiencies were cited during today's annual inspection. . The LPA provided technical advise, and advised the Licensee to maintain a copy of the Plan of Operation at the facility, store medication in their original container, and maintain a copy of the active administrator certificate at the facility. An exit interview was conducted with licensee Rathi, to whom a copy of this report, and Licensee Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Oct 4, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management visit. The LPA introduced himself and disclosed the purpose of the visit to Administrator Rathi. During today’s visit, the LPA assessed an immediate $500 civil penalty in an LIC 421IM form. This civil penalty was in response to a previously substantiated complaint allegation (Complaint # 08-AS-20191231162534). On December 31st, 2019, it was reported to the Department staff left a resident in soiled clothing. The Department investigated and substantiated the allegation on June 18th, 2021. During the visit, the LPA also delivered and amended LIC 9099D page, noting the deficiency was amended from a Type B to a Type A Deficiency. An exit interview was conducted with Rathi, to whom a copy of this report, LIC 421IM form, and the Licensee Appeal Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Oct 4, 2024

Type of visit: Case Management - Other

This is an amended report of a report originally signed on 10/04/2024. Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management visit. The LPA introduced himself and disclosed the purpose of the visit to Administrator Gaurav Rathi. During today’s visit, the LPA assessed an immediate $500 civil penalty in an LIC 421IM form. This civil penalty was in response to a previously substantiated complaint allegation (Complaint # 08-AS-20220912085344). On September 12th, 2022, it was reported to the Department Lack of supervision of a resident. The Department investigated and substantiated the allegation on October 12th, 2023. During the visit, the LPA also delivered and amended 9099D page, noting the deficiency was amended from a Type B to a Type A Deficiency. An exit interview was conducted with Rathi, to whom a copy of this report, LIC 421IM form, and the Licensee Appeal Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Oct 4, 2024

Type of visit: Case Management - Other

This is an amended report of a report originally signed on 10/04/2024. Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management visit. The LPA introduced himself and disclosed the purpose of the visit to Licensee Rathi. During today’s visit, the LPA assessed an immediate $500 civil penalty in an LIC 421IM form. This civil penalty was in response to a previously substantiated complaint allegation (Complaint # 08-AS-20190809110049). On August 9th, 2019, it was reported to the Department neglect resulted in a resident sustaining a stage 4 pressure injury. The Department investigated and substantiated the allegation on September 30th, 2020. At this time, pursuant to Health and Safety Code Section 1569.49, a civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division. An exit interview was conducted with Rathi, to whom a copy of this report, LIC 421IM form, and the Licensee Appeal Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Oct 4, 2024

Allegation investigated: Staff did not treat resident with dignity

On 11/13/2023, at about 12:00 PM, Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced facility visit to conclude a complaint investigation regarding the above-mentioned allegation. LPA identified himself and discussed the purpose of the visit and complaint conclusion with Hugo Duran, Administrator. On 8/1/2022, CCLD received a complaint alleging a staff person did not treat a resident with dignity. The Department’s investigation consisted of LPA observation, document and video recording review, and interviews with residents, staff, and outside sources. As a result of this investigation, LPA identified a former employee, later determined to be a person of interest in this complaint. LPA interviewed the former employee. The former employee said they lived at the facility but were off duty on 7/29/22. The former employee admitted to LPA they were involved in some type of physical confrontation with Resident 1 (R1). LPA asked the former employee if they picked up and threw R1 on to a bed. The former employee said they picked R1 up and carried them from the sliding glass Substantiated (Continued: LIC9099) door to their room. The former employee denied throwing R1 onto the bed and said they “set” R1 down. The former employee said they did this because R1 tried to run their scooter through a sliding glass door. Interviews with independent outside sources divulged that the former employee was impatient, had no people skills and lost their temper with residents. One outside source revealed that the former employee told them that they (former employee) were fired for physically assaulting a resident. The former employee said they lost their temper with a resident. In an interview with the former employee, they stated they resigned from employment with the facility in February 2023. The employee denied being terminated. Interviews revealed that facility management said the employee was “let go” but not due to circumstances associated with this complaint or any type of abuse to any resident. The Department has investigated the complaint alleging staff did not treat R1 with dignity. Based on interviews, sufficient evidence was obtained that a former employee did not treat a resident with dignity. The allegation that staff did not treat a resident with dignity is Substantiated. This finding means that the preponderance of evidence standard has been met and the allegation is valid. Deficiencies have been cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC9099-D. An exit interview was conducted with Mr. Duran, and a copy of this report and Licensee/Appeal Rights (LIC 9058 01/16) were provided to Mr. Duran at the conclusion of the visit. (Continued: LIC9099-A) R1's right forearm/wrist appears to be bleeding. The depiction of the video does not show how R1's arm and hand were injured but the injuries are consistent with the Incident Report sent to CCLD on 8/5/22. During this investigation, a former employee was interviewed regarding their involvement in a physical conflict with R1 on 7/29/23. The former employee was in their bedroom on this day when they heard R1 and staff yelling. The former employee went to the kitchen to investigate the commotion. The former employee observed R1 sitting on their scooter near the stove. The former struck R1’s hand which then struck a wall. The former employee said they struck the resident’s hand because they thought R1 may burn themselves on the kitchen stove. The former employee denied injuring the resident. Resident interviews did not produce corroboration for the allegation as no other residents were in the area. Residents advised LPA during interviews that R1 was difficult and disrespectful towards staff. None of the interviewed residents witnessed a staff person assault any resident or cause them injuries. The former employee later told an outside source that they admittedly lost their temper with a resident. The outside source did not say the former employee caused the injury to the resident. Per another outside source, R1 told them the former employee caused the injuries. However, the investigation produced no persons who witnessed any employee assault any resident. It was also alleged that staff destroyed R1’s personal belongings. An outside source reported that a former employee took R1’s telephone from them to keep them from making calls outside of the facility. A former employee was interviewed but denied damaging or taking R1’s personal property from them. Facility records were reviewed and indicated that R1 moved out of the facility and into a private residence on 7/31/2022. R1’s property was removed from the facility before the complaint was submitted. LPA reviewed R1’s facility records which noted that R1 had an electric scooter, walker, wheelchair and television. Staff interviews reported consistent denials that they damaged R1’s property. The Department has investigated the complaint alleging staff assaulted R1 which resulted in injuries and destroyed R1’s personal belongings. Based upon conflicting statements and inconclusive records, insufficient information was obtained to corroborate the allegations. The Preponderance of Evidence (Continued: LIC9099-C) Standard was not met. Therefore, the allegations are Unsubstantiated. An exit interview was conducted with Mr. Duran, to whom a copy of this report and the Licensee's Rights (LIC9058 01/16) were provided via hard copy.the state’s words, verbatim · CDSS document, Nov 13, 2023 · control 08-AS-20220801100505

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80072(a)(3) · Plan of correction due date: Nov 15, 2023

Personal Rights - ...(3) 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...This requirement is not met as evidenced by: Based on interviews, the licensee did not ensure a resident was free from corporal or unusual punishment…This posed an immediate safety risk to all residents in care.the state’s words, verbatim · CDSS document, Nov 13, 2023

Plan of correction: Subject employee was separated from employment with the facility in February 2023, removing the immediate threat. Licensee agreed to procure vendorized training on personal rights. Licensee will provide CCLD with the date for training by POC date of 11/15/2023 and complete the employee training and provide written proof by email or fax by POC date of 12/13/2023.