Incident investigation·November 4, 2025

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced Case Management visit to investigate the incident that occurred on 10/12/25 and reported to the Department on 10/17/25, regarding Resident #1. LPA Yee met with Aaron Mays, Designated Executive Director. The reason for today's visit was explained. Per information provided on the LIC624, Special Incident Report, Staff #2 observed Staff #1 push Resident #1. No other details were provided regarding the incident on the report. Upon further inquiry into the incident, the following was revealed. On 10/12/25, around 4am, Staff #1, who works the night shift was doing laundry and had left the laundry cart with Resident #2's clothes by their door and had stepped away. Resident #1, who has dementia was wandering around, grabbed a pair of Resident #2's pants from the cart. Staff #1 noticed and attempted to get the pants away from Resident #1. Resident #1 got mad and threw the pants on the floor and began stepping on it. Staff #1 and Staff #2 attempted to get the resident off the pants. Staff #1 got irritated and pushed the resident, causing the resident to fall on the floor and landing on their back. Staff #1 and Staff #2, both assisted Resident #1 to get up. Resident #1 walked with a limp. Per Staff #2, when they were changing Resident #1, a big bruise was observed on the resident's arm and bottom. This incident was reported to Staff #3 when Staff #2 returned to work later that evening. Staff #4 was not advised of the 10/12/25 incident until 10/14/25. Staff #1 who was off on 10/13/25, was suspended via telephone on 10/14/25 by Staff #4 and the designated Executive Director was also notified that morning. An internal investigation was attempted and Staff #1 was given the opportunity to come into the office continued on LIC9099-C Page 2. to provide a written statement of the incident that occurred on 10/12/25 and Staff #1 refused. Staff #1's employment was terminated on 10/17/25. On today's visit, LPA Yee interviewed Staff #4 at 11:49pm, Designated Executive Director at 12:14pm and reviewed and obtained documents from Staff #1, Staff #2 and Staff #3's files, documents from Resident #1's file. A copy of the facility's investigation was obtained. A copy of the video clip of the incident was also obtained during the visit. Per information obtained on today's visit, additional interviews and further investigation is needed to determine if the facility would be culpable for the action of the staff and if any further action is needed. LPA Yee will return to deliver her findings of her investigation once the investigation into the incident has been completed. Exit interview was conducted with Joanna Hernandez, Memory Card Director.