Incident investigation·November 12, 2025

At approximately 10:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit in regards to two SOC341, Report of Suspected Dependent Adult/Elderly Abuse, forms submitted by the facility and received by the Department on 11/06/2025 and 11/12/2025. LPA met with Executive Director Zenia Shah, interviewed staff and reviewed documents. The 11/06 incident involved a staff, S1, who grabbed a resident by the shoulders and pushed them down onto the bed, because the resident was resisting care. The incident was reported by another staff to the Director. S1 was terminated from employment on 11/06/2025. The 11/12 incident involved a staff, S2, who became upset with a resident and informed them that if they continued to resist care, he would physically restrain them. S2 was heard by numerous staff throughout the remainder of the day, saying they would restrain the resident and call to have them taken away and put on a 5150 hold if they continued to be combative. S2 did not physically restrain resident, only threatened the restraint. S2 was terminated from employment on 11/10/2025. LPA received copies of personnel files for S1 and S2. No citations issued during this visit.