Incident investigation·October 31, 2025

On 10/31/2025 at 1:30PM, Licensing Program Analysts (LPAs) Andrew Christy and Grace Luk arrived unannounced to conduct a Case Management visit regarding an Unusual Incident Report (LIC624) received on 10/29/2025. Incident involved a night shift staff member slapping a resident during care around 5:30AM. LPAs met with Executive Director San Sor and explained the purpose of the visit. Facility is currently at 95 residents with a max capacity of 121 residents. During the visit, LPAs collected the following documents: resident roster, employee roster, R1's Medical Assessment (LIC602), R1's Appraisal Needs And Services, R1's medication list, and S1's file. LPAs spoke to Executive Director to discuss what happened when the incident occurred and what steps have been taken to ensure that it does not happen again. Executive Director stated that they were informed of the incident that morning around 6:30AM. Executive Director was informed by S2, also a night shift employee that S1 reported bruising on R1's face, but the story of what happened during care has changed multiple times. R1 and R2 instead report that S1 was frustrated with them, and ended up slapping R1. A police report (#25-11309 with Officer F. Brooks) was filed after the incident, and S1 was called back in to explain their side of the story. Shortly after, due to the nature of the allegations and inconsistency of S1's story, S1 was put on leave until further notice. In regards for steps that have been taken ensure there is no future occurrence, Executive Director stated that there would be a new round of Mandated Reporter training. LPAs may return at a later time. No citations issued during visit. Exit interview conducted and a copy of this report was made available to the Executive Director