Incident investigation·September 26, 2024

Licensing Program Analyst (LPA) Michael Tea conducted a case management visit to follow up on an incident report received by Community Care Licensing (CCL) on September 23, 2024 submitted by Executive Director (ED), Jennifer Munoz. LPA was greeted and allowed entrance into the facility by Executive Chef, Jeremai Soto and explained the reason for the visit. ED Munoz arrived shortly to assist during the visit. During the case management visit, LPA and ED toured the facility. LPA conducted health and safety checks on residents present and confirmed they were doing well and observed no health and safety issues besides residents who have Covid-19. Facility is following public health Covid-19 protocol. LPA observed the facility to be clean and organized and found no health and safety issues. LPA checked perishable and non-perishable food supply and it was adequately stocked at time of visit. The purpose of this visit is to discuss the special incident report (LIC624) submitted that occurred on September 13, 2024 around 8:15 PM where Staff 1 (S1) observed Staff 2 (S2) physically placed their hand over Resident 1’s (R1) mouth who resides in Memory Care. LPA requested resident file, staff files, staff and resident roster and internal investigation summary report. LPA interviewed with ED Munoz, Memory Care Director (MCD) Samantha Shashkin and R1. S1 reported the incident at the end of their shift to the MCD Shashkin. ED Munoz conducted an internal investigation the following day, September 14, 2024. ED Munoz along with MCD Shashkin interviewed Memory Care staff, including S2 right before they started their shift. Management has pulled S2 off the floor and has placed them on administrative leave/suspension and employee status is pending after investigation. The ombudsman was contacted and local law enforcement was notified and reported the incident to them. The internal investigation was closed on September 18, 2024. Facility management concluded they were going to terminate S2 employment. (Report continued on LIC809-C) There were no health and safety concerns observed in the areas inspected. Based on the observations made during today’s visit the following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Executive Director, Jennifer Munoz and a copy of this report and appeal rights was provided at exit