Incident investigation·August 29, 2024

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Health Services Director Alyssa Ukaj. Administrator Geovanni Aguilar later arrived to meet with LPA. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office. According to the LIC624: on 6/17/24, Resident #1 (R1) was involved in an incident where staff restrained R1 in order to change a soiled brief after R1 went several hours refusing to be changed. [See LIC 811 Confidential Names List for a description of R1.] . No injuries reported. Facility reported incident to law enforcement, notified R1's responsible party, staff who were involved in the incident were written up and terminated, facility conducted in service training for all staff on personal rights, restraints and abuse/mandated reporting. During today’s visit, LPA performed a facility tour / welfare check, collected records, observed R1 and interviewed staff. One (1) deficiency was cited per California Health and Safety Code (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the Administrator. An exit interview was conducted with Aguilar, to whom a copy of this report, the LIC809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.