Incident investigation·November 8, 2023

On 11/08/23, LPA Bains conducted an unannounced case management visit to the facility to follow up on an incident which happened at facility on 05/31/23 related to 2 facility staff members. LPA met with administrator, David Bostanchyan and explained the purpose of today’s visit. The department conducted a record review to investigate this incident. Based on the records reviewed, it has been determined that the facility did not report an incident to the Department where staff, S1 made inappropriate sexual conduct to staff S2 on 05/31/23. Law enforcement was called and S1 got arrested due to this incident. Per facility records, S1 and S2 were ‘live-in’ staff at the time of incident. The facility should have reported this incident to CCL as required by Title 22. Although this incident did not involve residents but S1 and S2 were on duty at the facility and were responsible for the care and supervision of the residents ultimately putting the residents’ health and safety at risk. Additionally, it has been concluded that administrator was aware about this incident which happened at the facility between staff, S1 and S2 but administrator did not comply with reporting requirement. During today's visit, administrator stated that facility send SIR (LIC624) for this incident to CCL via Fax but facility could not provide any verification to prove it when LPA requested. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 809-D page. Exit interview conducted. Appeal Rights and copy of this report has been provided to facility.