Incident investigation·July 29, 2025

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to follow-up on an Unusual Incident Report received by the Regional Office. LPA was greeted and granted entry by the receptionist. LPA met with Danny Vera, Executive Director, and explained the purpose of the visit. LPA requested the following: Resident and Staff Rosters, and items from Resident #1 (R1)'s file. The items include copies of: Identification and Emergency Information, Physician's Report, Pre-appraisal Information, and Resident Care Theft and Loss Policy. LPA interviewed Resident #1 (R1) regarding the incident that occurred on July 14, 2025. The incident report stated a staff member intentionally crushed R1's finger. On July 15, 2025 Emergency Medical Services (EMS) transported to the local hospital, local law enforcement were called and an Elder Abuse Report (SOC 341) was filed with the Regional Office and the Long Term Care Ombudsman. The Responsible Party was also notified. R1 returned to the community on the same day with no new orders. X-rays revealed there were no fractures. LPA interviewed Resident #1 and three of three staff. R1 recounted the incident and stated it was not a finger, that it was the entire right hand. Upon staff interviews, three of three staff stated that the day of the incident, R1 acknowledged it was an accident and the ring finger of the right hand was evaluated. The alleged caregiver had apologized to R1, had immediately called the MedTech and the Health and Wellness Director visited R1 with medical options for care. The next day, R1 contacted local law enforcement and asked to be transported to the hospital for further evaluation. (Continued on LIC 809-C) (Continued from LIC 809) Based on the observations, record review and interviews 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, Executive Director and a copy of the report and files reviewed (LIC 811) were given at the time of the visit.