Incident investigation·January 26, 2026

On January 26, 2026, Licensing Program Analyst (LPA) Eboni Bentley made an unannounced case management visit for the purpose of following up on an SOC341 and Incident Report submitted to the Orange County Regional Office on December 18, 2025. The facility self-reported an incident where Staff #1 (S1) was accused of hitting and choking Resident #1 (R1) in their bedroom. Staff #2 (S2) reported hearing screaming while walking down the hallway, and responded to R1’s room, where they found R1 crying and both R1 and S1 accusing the other of being physically aggressive. A body check was conducted and two bumps were found on the R1’s head that were not previously reported. During the investigation, interviews were conducted with residents and staff. According to S1, the resident refused to go to the bathroom by screaming they did not want to up out of bed, and verbalized refusal repeatedly. S1 stated they ignored R1’s refusal when they pulled R1 up by the arms to a seated position in the bed, S1 placed their hand behind R1’s back to stand on the floor, and then proceeded to walk R1 to the bathroom, all while R1 was refusing to get up, and shouting at S1 to “leave me alone” and “get out.” Although there was not enough evidence to prove that S1 is the cause of R1 sustaining two bumps on the head, S1 admitted they should have stopped insisting R1 get out of bed and go to the bathroom for a shower, and should have called for assistance instead. S1 admitted they did not report the two bumps on head R1’s head. Three out of five individuals confirmed witnessing S1 being aggressive while caring for residents. No additional details were provided. Based on the interviews conducted during the investigation, a deficiency is being cited. An exit interview was conducted Executive Director Mandy Taylor, and a copy of this report and appeal rights were provided.