Incident investigation·September 5, 2025

Licensing Program Analyst (LPA), Hannah Rodgers conducted an unannounced case management visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Executive Director Jennifer Ortega. The facility self-reported an incident that occurred on June 1, 2025, and June 2, 2025, involving Resident #1 (R1), Resident #2 (R2), and Staff #1 (S1) [See LIC811 Confidential Name List for identification of select person identifiers used in this report]. The incident report indicated on June 1, 2025, S1 was rough with R1, by grabbing and pulling on both of R1’s wrists in order to get them out of their wheelchair. It was also reported that on June 2, 2025, S1 was witnessed pushing R2’s walker into R2’s knees after R2 would not comply with standing up as S1 had instructed. S1 was placed on suspension and their last day worked was June 2, 2025. S1 was officially terminated by the facility on June 3, 2025. During today’s visit, LPA briefly toured the facility, observed residents in care, reviewed and obtained copies of facility records, and interviewed staff and residents. Interviews with internal sources revealed that S1 was seen being rough R1 and R2 primarily during transfers. LPA attempted to interview R1 and R2, but due to their baseline memory loss, each was unable to be qualified as a reliable historian for this case. Review of R1’s physician’s report dated July 26, 2024, and R2’s physician's report dated June 18, 2025, revealed that both R1 and R2 have a primary diagnosis of Alzheimer's Disease, and both require assistance with all Activities of Daily Living (ADLs) except for feeding themselves. [CONTINUED ON LIC809-C] Review of S1’s Performance Counseling & Improvement Plan for Corrective Action signed and dated June 6, 2025, revealed that S1 did not follow the policy/company rule of abuse or neglect of a resident and was terminated as a result. One deficiency is being cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). An exit interview was conducted with Executive Director Ortega, to whom a copy of this report, LIC 809-C, LIC 809-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.