Incident investigation·August 25, 2025

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Case Management - Incident visit. LPA was welcomed by Susan O'Shaughnessy, the Director of Marketing and Admissions, and discussed the purpose of the visit. Today's visit was in response to an Incident Report (LIC624) that the licensee self submitted to the CCLD San Diego Regional Office. According to the LIC624, on 8/21/24, Resident #1 (R1) was involved in an incident where a Staff 1 (S1) had a physical altercation with R1. The video shows R1 and S1 hitting and pushing each other. R1 falls to the ground and crawls on the floor until they can get up, while S1 watched and does not assist R1. R1 is seen on the video wiping blood from their hand.  R1 tries to stop the bleeding with a tissue, while they bend over to wipe the blood from the floor.  Staff 2 (S2) came to the memory care unit, where they saw the cut on R1's hand and applied aid. R1 was taken to the emergency room, where the resident received four stitches.The facility did not notify R1's responsible party of the incident. During today’s visit, LPA performed a facility tour,  welfare check, collected records, observed R1, and interviewed staff. (Continued on LIC809C) (Continued from LIC809) Two (2) deficiencies were cited per California Health and Safety Code (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the Administrator. Pursuant to the California Code of Regulations, Title 22, Division 6, deficiencies are being cited on the attached LIC809D.  An immediate Civil penalty of $500 was assessed during today's visit for the facility's: To be free from punishment, humiliation, intimidation, abuse, or other actions, and the licensee shall provide for and encourage all personnel to report observations or evidence of such abuse. An exit interview was conducted with Administrator, to whom a copy of this report, the LIC809-D, the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.