Incident investigation·December 18, 2025

Licensing Program Analyst (LPA), Mayra Cota, conducted a Case Management – Incident visit today to follow-up on two (2) Special Incident Reports (SIR) received by the department. LPA, met with Jacqueline Cortez, Executive Director, and the reason for the visit was explained. According to the first SIR, date of occurrence 10/19/2025, a staff member (Staff 3/S3) raised their voice and made an inappropriate comment to a resident (Resident 1/S1) during an encounter in which R1 requested help. R1, reported the incident to the Executive Director (Staff 1/S1) and Care Coordinator (Staff 2/S2). According to interview with S1, S1 spoke to S3 to remind them that residents need to be always spoken to calmly and with respect. S1 stated that, S3 admitted to raising their voice and making inappropriate comment toward R1. S1 indicated that S1 and S2 assessed R1 after the incident and did not observe any injuries and R1 continued their normal routine the rest of the day. S1 indicated that S1 talked to S3 on 10/31/25 regarding the incident, and a formal meeting and write-up regarding professional conduct and resident standards took place on 11/12/25. During this meeting, the written notice was discussed and provided by S2 to S3. Interview with S2 indicated that S3 has been taken off assignment of R1’s room and is not allowed to enter R1’s room at any time. S2 stated that they monitor the assignments and ensure that S3 does not interact with R1. Interview with R1 indicated that S3 is not coming into their room anymore and is glad that staff were proactive after R1 reported the incident. ****Continues to LIC 809-C**** According to second SIR, date of occurrence 10/25/25, staff member (Staff 4/S4), was observed by a resident (Resident 3/R3) raising their voice toward another resident (Resident 2/R2) as R3 walked down the hallways by R2’s room. SIR also reports that S4 was heard yelling at R2, “Leave me alone you lunatic or I will call the cops.” Interview with S1 indicated that upon receiving the report from R3, S1 scheduled a meeting with S4 on 10/31/25, due to S4 working primarily during the night shift and S1 working during the day shift. S1 stated that during the meeting, S4 was suspended for further investigation. S1 took S4s statements and presented them to Human Resources. S1 indicated that they conducted the investigation and could not obtain any information from the alleged victim (R2) or other possible witnesses. S1 stated that they attempted to obtain more information from R2; however, R1 could not recall the incident. S1 indicated that due to insufficient evidence, S4 was reinstated to their job duties on 11/7/25; however, S4 still received counseling from S1 regarding expectations and protocols and working effectively with residents who may present behavioral challenges. S1 further indicated that S4 denied raising their voice at R2 and saying inappropriate statements. Interview conducted with R3 and R3 indicated that they heard S4 yelling loudly at R1 but could not remember what S4 said to R2 during the incident. LPA, attempted to interview R2, however, R2 was not responsive to LPA’s questions and stated, “I don’t remember that.” During today’s visit, LPA did not observe any potential or immediate health and safety risks to residents in care. A citation is issued today per California Code of Regulations (Title 22). Exit interview was conducted with Jacqueline Cortez, Executive Director, and a copy of this report, 809-D and Appeal Rights was provided.