Incident investigation·March 23, 2022

Licensing Program Analyst (LPA) Cuadra met with Angela Briles, Administrator for a case management visit to follow-up on incident reports received on 2/7/22 involving resident (R1) and resident (R2). On 2/6/22 there was an altercation between R1 and R2. Per Administrator, the two residents are not related and this was an isolated incident. R1 has some communication limitations and was in between moving rooms and the interim period was using the day room to watch television then there was an un-witnessed altercation between R1 and R2 when staff came in the room it appears like R1 had been pushed. Staff inquired about the incident and R2 admitted that they pushed R1 because R1 was apparently switching tv channel/volume. On 2/7/22 the day after the incident social workers met with R1 to try to resolve any issues. They suggested getting their comcast service transferred to their new room and their essentials moved in immediately and facility implemented the changes. Also, Public Safety (CHP) and (ERT) Emergency Response Team responded to the RCFE to interview both residents and check on their safety and well-being. LPA requested and obtained CHP incident Log# 1653 regarding incident and no further action is needed. During today's visit LPA reviewed records and made observations. Per Administrator, this was an isolated incident there are no changes to their needs and services plans, but the facility is still monitoring both residents very closely to prevent future incidents. Facility made the proper notifications and SOC341 was completed and forwarded to the correct parties per regulation. LPA also followed up on a SOC341 submitted to CCL on 2/28/22. This incident is involving two residents from another section of the Veterans Home and the responsible parties including law enforcement, Ombudsman and CDPH were notified. No deficiencies cited during this inspection.