Incident investigation·February 8, 2024

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management visit to follow-up on an incident report received by Community Care Licensing on 1/30/2024. LPA met with Executive Director (ED) Sheila Fike and explained the reason for the visit. Incident report indicated that on 1/28/2024, Resident 1’s (R1’s) girlfriend reported to Staff 2 (S2) that R1 informed her that on 1/25/24, Staff 1 (S1) asked R1 “do you want me to put my finger up your butt” to which R1 responded "no." During today’s inspection, LPA interviewed R1 in their respective bedroom. R1 confirmed the incident took place but was unable to provide details leading up to the incident, or where it took place. Per R1, they did not report the incident to staff, nor did they mention it to any residents. LPA interviewed R1’s girlfriend by phone and they confirmed R1 had informed them of the incident, but denied knowing specifics and stated they did not know the name of the staff alleged to have made the remark. During their interview, S2 stated that they had interviewed R1 after R1’s girlfriend reported the incident. Per S2, R1 confirmed the incident took place, but was unable to provide details regarding when and where it took place. ED stated during their interview, that S1 was immediately suspended pending an internal investigation. Per ED, internal investigation consisted of interviews with staff and residents and found the incident to be unsubstantiated. ED stated staff and residents denied witnessing or having any knowledge regarding the incident and reported no concerns regarding S1. Per ED, S1 denied the incident ever took place. ED stated they also do not have any concerns regarding S1. LPA interviewed S1 by phone during today’s inspection. S1 denied the incident ever taking place and stated they would never ask or make a remark such as the one being alleged. (Cont. LIC809-C) LPA reviewed R1’s Physician Report (LIC 602) dated 2/13/23. Per LIC602, R1 is diagnosed with dementia and at times is confused or disoriented. Based on information gathered and due to conflicting information provided during interviews, LPA is unable to determine if alleged violation did or did not occur and no further action is required. Based on observation’s made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.