Incident investigation·November 1, 2024

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit to follow up on an Unusual Incident Report that was received in our office on October 25, 2024. LPA was greeted and granted entry into the facility by the concierge at 2:30 PM. During today’s visit, LPA met with Danny Vera, Administrator (AD). LPA requested Resident #1's (R1) file and Staff #1's (S1) personnel record for review. There are no reports on file from Brea PD. LPA interviewed R1 at 2:45 PM regarding the incident that occurred on October 21, 2024 at 6:30 PM. R1 shared the events that happened that evening regarding a male staff member, S1 assisting R1 from the commode to bed. Upon transfer, R1 lost strength in her knees and S1 held her against the bed to support her and called for assistance from a second staff member, Staff #2 (S2). In the few minutes it took for S2 to arrive, R1 felt something hard pressed against her back. After S2 assisted S1 with the bed transfer and left, S1 mentioned to R1 that there was wetness on his leg to which R1 replied the wetness came from S1. LPA interviewed Staff #1 at 3:40 PM and showed the LPA the items carried in his scrubs pockets on his left side. Items include: small hand sanitizer, small contacts solution bottle, an eye dropper and a walkie-talkie radio. LPA inquired where the wetness was on his leg during the incident and S1 showed a spot just above the left knee. Staff #2 was not present for interview at time of visit. The facility submitted the Unusual Incident Report, the Mandated Reporter Abuse Form (SOC 341) and cross reported to Brea Police Department (PD) (Case #2410-2021), the Long Term Care Ombudsman (LTCO) and Community Care Licensing (CCL). Brea PD interviewed resident and involved staff members and the LTCO interviewed the facility. (Continued on LIC 809-C) (Continued from LIC 809) Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Danny Vera, Administrator and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.