Incident investigation·September 28, 2023

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management - Incident visit to the facility. The LPA was greeted by Administrator Joyce Aquino and informed them of the reason for the visit. The purpose of today's visit is to address a self reported Unusual Incident/Injury Report (LIC 624) reported to CCL on 09/17/2023. The self reported Unusual Incident/Injury Report (LIC 624) pertains to an incident that occurred on 9/17/2023 regarding Resident #1 (R1) and two staff (S1, S2). It was documented that at approximately at 1:15 a.m on 9/17/2023, S1 was observed by S2 removing R1's sweater in a rough manner, pulling/gripping R1's arms trying to lay R1 on their bed. It was further reported that when a Wellness Nurse went to check on R1, R1 stated "Are you going to hit me too?" A Wellness Nurse completed a skin assessment of R1's body and noted redness on her arm. During todays visit, the LPA conducted four (4) staff interviews, three were conducted via telephone call, obtained pertinent records and interviewed the administrator throughout the visit. Staff interviews revealed that R1 was heard screaming by three staff (S2, S3, S4), which was stated to be unusual behavior for this resident and cause staff to be concern and run to check on R1. S1 was observed by S2, forcefully gripping R1 to remove their sweater, and forcefully sitting R1. Staff interviews further revealed that R1 was observed crying after the incident by S5, and staff ensure to not leave R1 alone with S1 for the remainder of the night. Documents obtained revealed that R1 had been assesses by AM wellness nurse with redness/bruises on their left arm, however Administrator stated they were unsure if they were new or old as R1 had a fall on 9/14/23. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to 809-D). Exit interview conducted. Copy of report and appeal rights issued at the time of the visit.