Incident investigation·May 22, 2025

Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility on 05/22/25 to conduct a case management visit regarding and incident reported by the Memory Care Director. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator/Executive Director (ED). LPA met with Cal Mendiola and a brief interview followed. The Ombudsman was also present during this meeting as he was investigating the same incident in response to an SOC 341 that was sent. LPA Viarella received a phone call from the Director of Memory Care stating that R2 was found in R1's room and that R1 who was non ambulatory, was in bed, and naked from the waist down. During an interview with a staff member (S1), this LPA learned that R2 has a history of being aggressive and fixated on R1 who is non-verbal and unresponsive to R2's advances. S1 stated that R2 will sit with R1 and S1 has seen R2 stroke R1's leg and lap area. S1 told this LPA that when staff separate the two, R1 smiles and sits straighter in their chair. S1 stated that when R2 is with R1, R1 drops their head and does not make eye contact with R2. In care notes dated 02/08/25, another staff member (S2) had a conversation with R1's responsible party. The responsible party stated, "that R2 is controlling." They want to make sure, "that R2 does not take advantage of R1 in any way," During today's meeting the Ombudsman asked who was supposed to be watching to ensure the two were kept separated, since R1 did not have the capacity to give consent. S1 replied that S3 was assigned to R2 and was supposed to ensure that R2 did not go into R1's room. LPA Viarella interviewed S3 and learned that S3 went on break but did not tell anyone to take over watching R2. It was during this time period that R2 went into R1's room When S3 came back from their break, they heard voices in R1's room and S3 went and removed R2 from the room. According to the California Code of Regulations, Title 22, the facility was cited for a Personal Rights Violation which may be found on the LIC 809D page. The Memory Care Supervisor stated that she will be conducting an in service on personal rights and how to protect R1's personal rights as well as how to address the behavioral expressions of R2. Due to time constraints, this LPA will return to conduct a case management regarding reporting requirements. No other deficiencies were cited during today's visit, a copy of this report was provided. Exit interview.