Incident investigation·November 22, 2024

At approximately 9:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director/Administrator, Angie Boucher-Turin. The purpose of the visit was to follow up self-reported incidents that were submitted to Community Care Licensing (CCL). The Santa Rosa Regional Office (SRRO) received 9 late incident reports from the facility. Review of reports showed that incidents occurred on the following dates: 10/28/2024, 10/29/2024, 10/31/2024, 11/01/2024, and 11/03/2024. Reports were received by the SRRO on 11/12/2024. During LPA's visit, LPA discovered that Staff Member 1 (S1) did not submit the reports timely and that the Executive Director submitted the incident reports. Per Title 22 Regulations, incident reports must be submitted to CCL within seven (7) days of the incident occurring (deficiency cited, LIC809D, Regulation 87211(a)(1)). LPA followed up on the following incidents: Incident Report 1/SOC341: CCL received an incident report and SOC341 on 10/17/2024. Reports state that on 10/17/2024, Resident 1's (R1) family notified facility management of interactions between a facility staff member and Resident 1. Per R1's family, R1 stated to them that Staff Member 2 (S2) kissed them on two separate occasions. Facility made all appropriate notifications per regulation. Incident Report 2/SOC341: CCL received an incident report and SOC341 on 11/13/2024. Reports state that on 11/12/2024, facility management was informed by Staff Member 3 (S3) that they observed Staff Member 4 (S4) pinch Resident 2's (R2) nose and raise a hand towards them. Per report, the incident occurred 2 months prior. Facility made all appropriate notifications per regulation. Incident Report 3: CCL received an incident report on 11/20/2024. Reports state that on 11/18/2024, facility staff notified Executive Director that a former resident's medication was missing. Per report, the missing medications were discovered on 11/18/2024. Facility made all appropriate notifications per regulation. Continued on LIC809C Continued from LIC809 Per discussion with ED, internal investigations are ongoing and they have been in contact with the San Rafael Police Department regarding the incidents. LPA requested and reviewed documents, and conducted interviews. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D (Deficiency Page), Confidential Names (LIC811) Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.