Incident investigation·December 2, 2025

On 12/2/2025 at 2:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to SOC341. LPA met with Executive Director, Aireen Tibon and informed her the reason for the visit. Based on the SOC341, staff (S3) grabbed a resident (R1) by the arms forcing R1 to stand up. This action resulted in R1 sustaining a skin tear on R1's arm. During visit, LPA interviewed staff and resident. LPA reviewed R1 and S3's files. Interview with staff indicated that S2 witnessed the incident where S3 grabbed R1's arm which caused a large skin tear on R1's right arm. Interview with R1 revealed R1 did not remember how the injury on right arm was sustained. LPA was informed that the facility conducted an internal investigation and S3 was terminated. Facility conducted an in-service training on resident rights shortly after incident occurred. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.