Incident investigation·April 9, 2025

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management Incident inspection at the facility today. The LPA met with Administrator Joeyvic Alvarado and explained the reason for the inspection. On 03/21/2025, Community Care Licensing (CCL) received two (2) Unusual Incident/Injury Report (LIC 624) and two Self-Reports of Suspected Dependant Adult/Elder Abuse (SOC341) pertaining to Resident #1 (R1), Resident #2 (R2), Staff #1 (S1) and Staff #2 (S2). The first Incident report and SOC341 reported that on 03/20/2025, R1 was sitting on their chair by the window with their table in front of them, on their table there was a tray with their dog's food in a bowl with paw prints and R1's food in a container from the communities kitchen. S1 and S2 were with R1. R1 pointed at their dog's bowl and told S1 to warm up their food. R1 has poor vision. S1 warmed up the dog bowl, meanwhile S2 turned around as they did not want to see R1 eat the dog food and S1 gave it to the resident. R1 spat out the food and said "this is nasty, it's my dog's food." S1 took the food away and warmed up the correct food and gave it to the resident. S2 reported the incident to management. The second incident report stated that 03/20/24, S2 observed S1 be rough with R2 as S1 was assisting R2 in moving their legs to bed. It was further reported that the Administrator spoke with R2, who denied any staff had been rough with them. On 03/21/25, LPA Cortez spoke with the Administrator on the phone. The Administrator stated that S1 was suspended, S2 will receive training on intervention, incidents were reported to ombudsman, resident, residents family, residents physician and Licensing. All the appropriate actions were taken. Report will continue on LIC809-C, 2nd page. During today's visit the LPA conducted a file review and conducted interviews with R1, R2, S1 and the Administrator. Interviews with R1 confirmed that they had been given dog food, that the staff was careless and the incident made them feel diminished. Interviews with R2 revealed that they have no concerns with the care being provided and they denied staff being rough with them. Phone interview with S1 revealed that S1 did not know that the food in the bowl was dog food, gave R1 the dog food in error as they were was just doing what R1 was asking them to do, even though S2 at one point mentioned it did not look like human food. Furthermore, S1 denied being rough with R2 or any of the residents. File review revealed that S1 had previously been given a corrective action notice for neglect/ not providing appropriate care to residents prior to this incident. The LPA was not able to interview S2. Lastly, interview with the Administrator revealed that as of 03/31/25, R1 no longer works at the community and that all staff were trained on reporting abuse. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D).Civil penalty was issued. Exit interview was conducted and a copy of the report and Appeal Rights were issued.