Incident investigation·May 7, 2024

Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit to issue a deficiency after the department followed up on the incident that occurred on 10/3/23. LPA met with Administrator, Liyon O’Quinn, and explained the reason for this visit. The Department of Social Services Investigation Branch Investigator Veronica Padilla investigated the death of Resident #1 (R-1). Based on the information gathered, it revealed that Staff #1 (S-1) and Staff #2 (S-2) had been neglectful towards R-1. R-1 was found on the bathroom floor on 10/3/23 and sustained injuries. R-1 died 4 days later in the hospital. Interviews with S-1 and S-2 revealed that they failed to check on R-1 timely during their shifts. R-1 had a fall and was discovered by S-1 at around midnight on 10/3/23. S-1, who works the overnight shift, did not check on R-1 until the staff heard moaning noises coming from the room. S-1 immediately called 911 and was transferred to the hospital. Another staff (S-2) admitted that during the last 4 hours of the shift on 10/2/23, staff did not check on R-1. During the investigation, S-1’s personnel file was reviewed. It was discovered that S-1 has a reputation for being neglectful and showed misconduct when the staff was found sleeping on the job and in a resident’s room. On 9/6/23, a staff assigned to work alongside S-1 stated that S-1’s attitude toward a higher authority was rude and unprofessional. On 9/7/23, a staff observed S-1 coming out of R-1’s locked room and appeared to have just woken up. On 12/6/23, 3 staff members witnessed S-1 sleeping on the job. Staff provided written statements to confirm their observations. Based on record review and interview, it is determined that the facility did not provide proper supervision to the resident in care. A deficiency is being cited on the LIC809D, per the California Code of Regulations, (Title 22, Division 6 and Chapter 8). An immediate Civil Penalty of $500.00 is being issued due to the violation that resulted in the injury of a person in care. Refer to LIC 421IM. An exit interview was conducted. A copy of this report, appeal rights, and Plan of Corrections were provided to the administrator.