Incident investigation·May 9, 2025

Licensing Program Analyst (LPA) Hanna Gough conducted an unannounced case management incident inspection for the purpose of following up on an incident report submitted to the Orange County Regional Office. LPA was greeted and granted entry by staff and met with Executive Director (ED) Maria Domingo. The incident report was submitted to the regional office on May 1, 2025 stating that Resident #1s (R1) responsible party contacted the facility informing them that the resident stated that someone had “Dragged them to the bathroom”. Per the incident report a body check on R1 was made and no injuries were noted. R1 then stated to facility staff “They were being pushed in their wheelchair too fast so it felt like they were getting dragged”. LPA reviewed documents and interviews were conducted at the time of the inspection. LPA reviewed R1s physicians report which states that R1 has a diagnosis of dementia. During interviews with Staff #1(S1) and Staff #2(S2) it was revealed that R1 was unable to recall who the caregiver was that was pushing the wheelchair and when staff asked to elaborate on being dragged R1 stated they were “Being pushed in their wheelchair and it felt like they were being dragged”. S1 and S2 both informed LPA that they have noticed a pattern of sundowning behaviors with R1 and have informed the responsible party and physician of the change in behavior. S1 has set up a meeting with R1s responsible party to go over their plan of care due to R1s change in behavior along with aggressive behaviors that have been noted towards staff. S1 informed LPA that they had a voicemail of R1s responsible party stating that they, “May have used strong wording and that R1s state of mind may not have been at 100%,” when informing the facility of the incident. R1 is currently in the hospital due to swelling in both legs and confusion. Based on interviews and observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Executive Director Maria Domingo and a copy of this report was given at the time of the visit.