Incident investigation·March 27, 2026

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on SOC 341's submitted to the department on 02/05/2026 as well as an incident report. LPA was greeted and granted entry into the facility and explained the reason for the visit. SOC 341 dated 02/05/2026 indicated a caregiver had noticed bruising and bleeding on Resident 1(R1). Upon reviewing video surveillance it was determined that S1 had been rough with the resident. LPA reviewed the video footage and observed the staff being rough with the resident. SOC 341 dated 02/05/2026 indicated a caregiver had witnessed S1 being aggressive with R2. Video surveillance confirmed the staff was aggressive with the resident. LPA reviewed the video footage and observed the staff being aggressive with the resident. S1 was terminated effective 02/05/2026 and law enforcement was notified. LPA obtained the video surveillance during the visit. Incident report dated 03/14/2026 indicated medications were being passed in R3 and R4's room. R3 became ill and vomited. While assisting resident, caregiver put R3's medications down unsupervised and R4 consumed seven medications prescribed to R3. Normal protocol is for caregiver to pop the pills and hand to the resident and this protocol was not followed during this incident. Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.