Follow-up on corrections·December 8, 2023

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced, subsequent Case Management visit to cite a deficiency resulting from an incident self-reported by the licensee. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Chief Operations Officer / Administrator Carl Measer. On 08/11/2023, the CCLD San Diego Regional Office received an SOC341 Report of Suspected Dependent Adult/Elder Abuse from the licensee. Per the SOC341: on 08/09/2023, Resident #1 (R1) told Staff #1 (S1) they wanted to leave their bedroom and sit in the facility’s lobby. [See LIC811 Confidential Names List for a description of person identifiers used in this report.] S1 tried to stop R1 from doing this, placing hands on R1. This did not cause injury, but it caused R1 to become frightened. CCLD’s investigation involved a 09/14/2023 facility tour and welfare check, review of pertinent care and administrative records, and interviews of R1 and relevant staff. During today’s visit, LPA again toured the facility and interviewed additional staff. According to R1’s LIC602 Physician’s Report (dated 12/16/2022): R1 was diagnosed with Mild Cognitive Impairment. Their doctor determined that R1 was not safe to leave the facility unassisted and was “occasionally” confused in the morning, yet R1 remained able to follow instructions and able to communicate their needs. During interview of R1, LPA observed that R1 was vision impaired. R1’s recollection of the incident was coherent, and they were able to be qualified as a credible witness. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Interview of R1, corroborated by multiple staff interviews, showed: During the 08/09/2023 shift, S1 was a contracted home care worker hired by and working under the direction of licensee (rather than working for R1). S1 was therefore acting as one of licensee’s direct care staff. For a brief period of time, S1 repeatedly tried to stop R1 from leaving their bedroom to sit in the facility’s lobby. R1 did not fall and was not injured. R1 said they did not believe S1 was trying to hurt them, but S1’s actions offended and frightened them. CCLD’s investigation did not conclude that S1’s actions towards R1 rose to the level of willful physical abuse. However, a preponderance of evidence does exist to show that S1 violated R1’s personal rights by not allowing R1 to make a choice concerning their daily life at the facility. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Measer, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.