Incident investigation·December 27, 2023

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of following up on a self-reported incident and suspected abuse report. LPA met with Administrator Joyce Aquino. LPA explained the reason for today's visit. Entrance interview conducted. Previously, on 12/19/2023, on duty LPA Emily Peraldi received a telephone call from the Administrator indicating an alleged incident had been reported to the facility Management involving Staff #1 (S1) inappropriately waking up Resident #1 (R1). Administrator indicated a suspected abuse report would be sent to the Woodland Hills Regional Office the following day. LPA Dulek then reviewed the document, which indicates that on 12/16/2023, S1 told Staff #2 (S2) to wake up R1 by pinching R1's nipples. Administrator indicated the facility is conducting an internal investigation and S1 is suspended during the investigation. Administrator sent photos to LPA Peraldi of R1's chest area, which did show bi-lateral bruising. During today's visit, LPA interviewed Administrator and Director of Compliance at 09:55AM, toured the facility with Director of Compliance at 10:06AM, LPA gathered and reviewed copies of pertinent documents and interviewed staff between 10:38AM and 11:45AM. Record review revealed that R1 resides in the facility's Memory Care unit and requires assistance with most ADLs, including grooming, hygiene, transfers and escorts. Interviews revealed that R1 is tired frequently, most often after meals, R1's family prefers they not rest sometimes, and that R1 can be difficult to arouse when in a deeper sleep. Interviews and written staff statements obtained during the facility's internal investigation did indicate staff have been told by S1 that S1 has awoken R1 by pinching R1's nipples and had instructed other staff to do the same when they are having difficulty waking up R1. Multiple staff reported being aware of this statement made by S1. Photographs of R1's chest area showed bruising on both sides of R1's chest, near their nipples, which appears consistent with pinching. 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 were reviewed and issued during today's visit.