Incident investigation·August 29, 2023

On 8/29/2023 at 9:40 AM, Associate Governmental Program Analyst (AGPA) and Licensing Program Analyst (LPA) L. Francisco and A. Gomez arrived unannounced to conduct a Case Management to following multiple incident reports submitted to CCLD. AGPA and LPA met with Executive Director, Julie Mammad, Director of Social Services, Caroline Allen, and Resident Care Coordinator, Jetrey Inarda, and explained the purpose of the visit. On 7/14/23, CCLD received an incident report indicating R1 was exhibiting low oxygen level and other symptoms. According to S2, PCP and R1's responsible party was notified and R1 was taken to the hospital by R1's responsible party because R1's oxygen was not at a critical level. AGPA and LPA discussed the facility's procedure of when to call emergency. On 8/1/2023, CCLD received an incident report where R2 alleged S3 was being rough with R2 after a shower. According to the incident on 7/27/23, S3 was drying R2 with a towel "so hard that it hurt". Interview with S1 and S2 revealed that an internal investigation was conducted and S3 was suspended. It was determined after a 4 day of investigation that there were no other complaints from other residents. S1 and S2 stated that R3 is sensitive and on a lot of pain management. Staff were retrained to pat dry the resident with a towel after a shower and is now placed on a 2-person assist. In addition, S3 was reassigned to care for other residents. CCLD received multiple incident reports regarding S4 that occurred on 3/19/2020, June of 2020, and 8/15/2020. Based on record review of incident reports, it was alleged S4 caused bruising on R3's left lower arm and sustained a large skin tear on top of right hand and nose was sore. On June of 2020, S5 overheard S4 telling S5 that when R4 does not sit still or listen, S4 "motioned flicking S4's own arm" to make R4 sit still. On 6/28/2020, R4 was interviewed by S6 and R4 identified S4. REPORT CONTINUES ON 809C According to S1, an internal investigation by the union and S4 was terminated on 8/20/2020. However, according to S1, it was not determined whether the internal investigation resulted in substantiated or unsubstantiated. AGPA and LPA requested a copy of internal investigation to be submitted to CCLD via email by 9/8/23. No deficiencies cited during visit. Exit interview conducted with Executive Director and a copy of this report provided.