Incident investigation·October 25, 2023

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Geovanni Aguilar and Resident Services Director Tatiana Soltero. Today's visit was in response to two (2) LIC624 Incident Reports and two (2) SOC341 Reports of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office on 09/08/2023. The reports described alleged personal rights violations committed by Staff #1 (S1) against Resident #1 (R1) and Resident #2 (R2) on 09/05/2023, and which had since come to the licensee’s attention. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report]. During today’s visit, LPA performed a facility tour and welfare check on R1 and R2, finding that both were safe. LPA also collected copies of pertinent care records and interviewed multiple relevant staff. According to R1’s latest LIC602 Physician’s Report (dated 05/09/2023): R1 was diagnosed with “senile degeneration of the brain / dementia.” According to R2’s latest LIC602 Physician’s Report (dated 04/11/2023): R2 was diagnosed with “expressive language disorder” and “other unspecified disorders of the brain.” Manager and staff interviews unanimously showed that both R1 and R2 were cognitively-impaired as part of their baseline condition. LPA likewise observed that neither R1 nor R2 had the memory skills or verbal skills to be reliable interviewees. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Staff interviews, corroborated by time and date-stamped records, showed: During the evening of 09/05/2023, R1 did not want to receive personal care from S1. S1 used their own hands to physically restrain R1’s hands. S1 then used their fingers to pinch R1’s neck and spoke disrespectfully about R1 in front of them, towards Staff #2 (S2), who witnessed the above. Also during the evening of 09/05/2023, R2 did not want to receive bathroom assistance from S1. R2 was in their wheelchair and grabbed onto the doorframe of their bathroom in protest. Rather than stop, S1 continued to pull on R2’s wheelchair handles until R2 slid out of the wheelchair and onto the floor. This latter act was witnessed by S2 and Staff #3. Staff #4 did not witness the moment R2 slid out, but responded post-incident and corroborated that they personally helped R2 up off the floor. R1 and R2 did not suffer observable injuries from the incident. Records and staff interviews unanimously showed: Licensee became are of the above incidents on 09/06/2023, and immediately placed S1 on administrative leave pending further investigation. The same day S1 was placed on leave, they resigned from employment. Licensee’s own internal investigation concluded that S1 had committed the above alleged actions. A preponderance of evidence exists to show that during the incidents in question, licensee’s staff (S1) did not ensure that residents in care (R1 and R2) were free from humiliation and physical abuse. 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 Aguilar, 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.