Incident investigation·May 20, 2025

On 5/20/2025 at approximately 10:30 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced subsequent Case Management visit to the facility. LPA was greeted by staff and stated the reason for their visit was to deliver the findings regarding the incident reported to Community Care Licensing Division (CCLD) on 5/2/2025. Executive Director (ED) Katherine Aleman arrived shortly after to assist with today’s visit. Upon arrival, LPA requested Census, Staff and Resident Roster. At approximately 10:40 AM LPA requested additional documentation pertaining to the incident. Between 11:00 AM – 12:00 PM, LPA conducted additional interviews with Staff members (S5-S6). To investigate the incident, on 5/5/2025 LPA conducted a physical plant tour, requested pertinent documentation, and conducted interviews with one (1) Resident (R1) and four (4) Staff members (S1-S4). The facility reported that R1 had reported that S1 used inappropriate physical force towards them causing them pain. LPA spoke with the ED regarding the incident between R1 and S1. The ED stated that when they became aware of the alleged incident, they proceeded to conduct their own internal investigation as well as reporting the incident to the appropriate domains. The ED stated they interviewed both R1 and S1 but since there were no witnesses their investigation was inconclusive. LPA’s interview with R1 revealed that S1 had arrived in their room in the morning to assist them in bed with their incontinent care needs. R1 stated that S1 pushed their head down twice by placing their finger onto their forehead to get their head onto the bed. When LPA asked if they could name the staff member, R1 could not remember and stated, “I am not good with names”.When LPA asked if they had told anyone what had occurred, R1 stated they told S3 what had occurred. LPA’s interview with S3 revealed that R1 had told them that a staff member had “manhandled” them when assisting them in the morning. When LPA asked if R1 had told them the name of the staff member, S3 stated that R1 did not know the name of the staff member. (Continue to LIC 809-C) LPA’s interview with S1 revealed that they went to R1’s room in the morning to assist them with changing in bed. S1 stated that R1 has had surgery to their neck causing them to keep their neck in an upward position. S1 stated that when they changed S1, they placed a pillow behind their neck to help with their positioning. When LPA asked if they ever used their fingers to push R1’s head back towards the bed, S1 stated, “No, that is why I use the pillow to help position them”. While interviewing R1, LPA observed R1 keeping their neck in an upward position creating distance from their pillow to their neck. LPA’s Interview with S6 revealed that R1 did name S1 as the person involved in the incident however, interviews with S2-S6 revealed although R1 stated that said incident occurred, there were no witnesses. Furthermore, based on interviews, record review and observation there is not enough evidence to prove that S1 physically hurt R1. No deficiencies cited at this time. No immediate health and safety hazards observed during the visit. Exit interview conducted and a copy of this report was provided to the Executive Director.