Follow-up on corrections·December 30, 2021

On 12/30/21 at 10:30 AM, Licensing Program Analyst (LPA) Jaclyn Avila conducted an unannounced case management visit concerning two incident reports that were submitted to Community Care Licensing (CCL) on 12/16/2021. LPA met with Executive Director (ED) Eric Perry and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Roseleaf Senior Care and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: PAPR. LPA completed the facility screening questionnaire. The first of two incident reports submitted on 12/16/2021 detailed that on 12/15/2021 near dinner time. S1 (staff 1) was witnessed entering R1’s (Resident 1) room with the intent to administer prescribed medication. S1 requested S2 grab resident’s legs. S1 was witnessed holding R1’s wrists against R1’s chest then placing the medication in R1’s mouth via syringe. S1 was then witnessed placing S1’s hands over R1’s mouth. Executive Director (ED) upon being notified of the incident notified R1’s responsible party, Ombudsman and Community Care licensing. Per the incident report medical treatment was not needed and S1 was suspended. The second incident report submitted to CCL on 12/16/2021 detailed that on 12/15/2021 at about 8 PM, S1 was witnessed entering R2’s room with the intent to “change” R2. S1 was allegedly witness holding R2 by the thumbs and hands even after it was suggested a different method be used. S1 was allegedly witnessed stating to R2, “that’s why you’re here, this is your prison sentence.” ED upon being notified of the incident reported to S2’s responsible party, ombudsman and CCL. Per the incident report medical treatment was not needed and S1 was suspended. cont'd on 812-C This department investigated the incident which consisted of document review and interviews which revealed that on 12/15/2021, S1 held R1 down by pinning both wrists against R1’s chest. S1 did this to administer crushed medication into R1’s mouth that R1 often refuses. S1 later restrained R2, who had documented behaviors, in order to change R2. The facility investigated the incident and spoke with S1 who admitted to knowing S1’s actions were wrong. Per the facilities investigation S1 admitted to holding R1 to get R1 to take medication and admitted to holding R2 to change him. ED reported to the responsible parties, ombudsman and CCL as required. ED however did not report incident to law enforcement within 24 hours as required. ED called in the reportable incidents to the Chico Police Department on 12/30/21 during the CCL site visit. ED terminated S1 on 12/27/21. Both residents have memory care related conditions. The facility interviewed the residents shortly after the incident and neither resident could recall what occurred. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights provided. Report provided via e-mail.