Incident investigation·July 25, 2024

On 7/25/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding the LIC 624 Unusual Incident/Injury Report the Department received. LPA met with new Executive Director, Deborah Taylor, and explained the purpose of the visit. The incident occurred on 7/17/2024 when R1 reported to staff that S1 had threatened R1 to stop utilizing the call light or else S1 will rip the call lights out of the wall. R1 disclosed R1 is afraid to utilize call light after this incident. Facility conducted an investigation and S2 confirmed the incident had taken place as S2 was a witness of the encounter when S1 stated that if R1 does not stop pulling the call lights, S1 will move R1's bed. Facility has since placed S1 on suspension, and S1 is no longer working at the facility. Facility notified Community Care Licensing, Long Term Care Ombudsman and responsible party of this incident. LPA and Regional Director discussed that S1's last shift was the date of the incident. As a result of the incident of S1 violating CCR Title 22, Section 87468.1 Personal Rights of Residents in All Facilities, please see LIC 809-D. Exit interview conducted an a copy of the report and appeal rights provided.