Incident investigation·September 27, 2023

Licensing Program Analyst (LPA) Claudia Gutierrez conducted an unannounced case management visit for the purpose of following-up on an incident report submitted to the Department on 9/07/23. LPA was greeted and granted entry by Staff Edy ”Janet" Santiago and explained the purpose of the visit. Administrator (AD) Carmen Rodriguez was contacted by phone and arrived at 2:20 p.m. Incident report indicated that Staff 1 (S1) and Staff 2 (S2) had reported irregularities regarding Staff 3 (S3). An internal investigation was conducted, and no irregularities were found. The decision was made to relocated S3 to a sister facility and no further incidents have been reported. LPA interviewed S1 who stated S3 had been causing injuries to residents while assisting them with Activities of Daily Living (ADLs). S2 was also interviewed and corroborated S3 had been causing injuries to residents. LPA interviewed six out of six facility residents. Four out of six were unable to confirm or deny if staff has caused them injury while assisting them. Two out of six residents denied being injured by staff intentionally or otherwise. LPA interviewed two additional staff, who denied ever witnessing S3 causing physical harm or injury to residents. LPA interviewed S3 who denied ever causing physical harm or injury to residents. During today's inspection, LPA interviewed AD, who denied ever witnessing S3 causing physical harm or injury to residents. LPA presented AD with pictures obtained of residents with discoloration to one resident's lip, and a skin tear from the top of one resident's arm to their elbow with discoloration encompassing most of the bottom of the arm. AD confirmed the injuries were of current and past residents and stated the injuries had been self-inflicted, however, none of these incidents were reported to the Department; a Deficiency is being cited on today's date. Due to conflicting information received during interviews conducted with facility staff and residents, LPA is unable to determine if S3 has caused physical harm or injury to residents, and there is not a preponderance of evidence to prove S3 did cause physical harm or injury to residents. No further action is required.. Based on observations made during today's inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was left at the facility.