Incident investigation·March 27, 2024

On 3/27/2024 at 1:50 PM Licensing Program Analyst (LPA) A. Gomez arrived unannounced to continue a Case Management visit in regards to an unusual incident report received 2/06/2024. LPA met with Executive Director, Caroline Frangieh and explained the purpose of the visit. It was reported that on 02/02/2024 that a team member allegedly observed another team member push a resident living in memory care. It was found that the incident actually occurred 1/31/2024. Resident was observed to have no injuries or recollection of the event. Resident did not fall as they were near a wall and was able to stabilize thyself. Health Services Director, Anelisse Ramirez-LVN, was called to assess for possible injuries. Assessment resulted in no visible injuries. Resident was asked about the event, which they were unable to recall. LPA interviewed witness S2 with the help of Health Services Director, Anelisse Ramirez to translate. S2 stated that while they were pushing the dish cart from the kitchen R1 was wandering in their briefs and approached S2 to ask a question. S2 responded with "OK" because they do not speak English. S2 then returned to the kitchen and came back out a few minutes later. S2 then observed R1 walking down the hall towards S1 who was looking at their phone. S1 ignored R1. S2 speculates that R1 was asking S1 to go to the bathroom based on the body language of R1. R1 raised their voice repeatedly to get the attention of S1 but S1 maintained looking at their phone. S1 then reached over to the left with phone still in hand to push R1 away. R1 then stumbled and braced thyself against the wall. S2 states that R1 looked down after balancing thyself and then walked away. S1 then made eye contact with S2 and rolled their eyes. S2 later reported what they witnessed. Report continues on LIC 809-C Resident was in memory care and unable to recall. At the time of visit resident was no longer at the facility. LPA spoke with ED about addressing reporting requirements for mandated reporters and ED informed LPA that they provided S2 as well as all facility staff with a training on the expectations. THE FOLLOWING DEFICIENCIES ARE BEING CITED S1 was observed physically abusing R1 The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.