Incident investigation·April 10, 2025

Licensing Program Analyst (LPA) Erica Mosley conducted a Case Management - Incident visit to follow up on a self-reported incident which took place on 04/03/2025. At 9:45 a.m. LPA Mosley was greeted by staff and Administrator, Omowunmi Balogun and the reason for the visit was explained. Entrance interview. On 04/02/2025, it was reported that Resident 1 (R1) made the accusation to the Administrator that there are no staff at nighttime, R1 had an altercation with Staff #1 (S1) where S1 attacked R1 and staff serve the same meal every day. During today's visit, from 9:45 a.m. LPA conducted a physical plant tour to ensure there were no immediate health and safety concerns. On 04/09/2024 from 12:46p.m.- 2:20p.m. LPA conducted a brief physical plant tour, conducted in person interviews with the Administrator, two (2) staff including S1, three (3) residents including R1, a file review and obtained copies of pertinent documents relevant to the incident. On the accusation that there are no staff at nighttime the LPA conducted interviews with the Administrator, two (2) staff, and three (3) residents including R1. Interviews with the staff revealed that they always have staff at night. They have two (2) live in staff who are readily available. Staff state they regularly have two (2) staff scheduled throughout the day and night. There are always staff available. They have never left the residents alone at night. Interviews with residents revealed that they always have staff at night. They have not been left alone without any staff. Interview with R1 revealed that one morning, day unknown at 5:00 a.m. staff took longer than normal to assist and was upset that the staff took longer than usual. R1 stated that they do have staff at night. R1 stated that S2 is available at night and helps regularly. R1 stated that they were upset with the staff and told the Administrator that no one was here. Report continued on LIC 809-C PAGE 2... (PAGE 2) REPORT CONTINUED FROM LIC 809... Interview with the Administrator revealed that they have staff regularly scheduled and always have staff at night. R1’s California Department of Health Care Services (DHCS) Case worker (CW) was made aware of the accusation and came the next day to speak to R1 and gave the facility interventions for R1. On the accusation R1 had an altercation with S1 where S1 attacked R1 the LPA conducted interviews with the Administrator, two (2) staff including S1, and three (3) residents including R1. Interviews with that staff revealed that they are unaware of any altercation with R1 and S1. S1 did not attack R1. S2 stated that there has not been any altercation with R1 and S1.S1 did not attack R1. S2 stated that R1 was upset with S1 for telling R1 to not open the door to strangers and that the Staff would open the door for their safety. R1 then proceeded to yell and use profanity towards S1 and stormed off. Interview with S1 revealed that S1 did not get into any altercation with R1. R1 was upset with S1 for telling R1 to not open the door to strangers. Interview with R1 revealed that they did not have any physical altercation with S1. S1 did not push or put their hands on R1. S1 did not attack R1. Interview with the Administrator revealed since the accusation an Inservice training was conducted on 04/04/2025 with all the staff on Abuse, Abuse reporting procedures, Resident Rights, and Effective communication. On the accusation staff serve the same meal every day the LPA conducted interviews with the Administrator, two (2) staff, and three (3) residents including R1. Interview with staff revealed that they do not serve the same meal everyday and have photo proof of what is served daily. Staff follow a monthly menu that cover all nutritional guidelines. Interview with residents revealed that the same meal is not served every day, and the food is of good quality. Interview with R1 revealed that the facility does not serve the same meal everyday but that the food is not to their liking. R1 would prefer food that is culturally aligned with their culture. R1 states that the food is okay and good quality but not to their liking. Interview with the Administrator revealed that the facility has mad efforts to bring in more of R1’s culture into the food they provide. No deficiencies were observed during today’s inspection. Exit interview conducted. Report was reviewed and a copy was provided.