Incident investigation·December 30, 2024

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Assistant Resident Service Director Starsha Borja. Executive Director Mike McCoy and Resident Service Director Evalyn Valaile arrived during the visit. Today's visit was in response to a self-reported incident of Resident 1 (R1) found chewing on two pencil sharpeners during arts and craft resulting in staff finding two single razor blades in R1's mouth. [See LIC811 Confidential Names List.] During today’s visit, LPA performed a brief facility tour and welfare check on R1. LPA also collected copies of and reviewed R1's care and medical records. According to their latest LIC602 Physician’s Report, R1 was diagnosed with Alzheimer's disease and Dementia. Due to their baseline memory loss, R1 was not able to serve as a reliable historian/interviewee for this case. Staff interviews unanimously showed: Resident's are not to be allowed access to pencil sharpeners due to safety concerns. Sharpeners were to be used by staff to sharpen resident's pencils. Staff interviews further show: R1 has a history of putting inedible objects into their mouth and there is no consensus on how R1 obtained the sharpeners. Direct cares staff were supervising R1's floor (the first floor), activity staff were on the second floor conducting a different activity. One (1) deficiency was cited per California Health and Safety Code. An exit interview was conducted with Executive Director Mike McCoy and Resident Service Director Evalyn Valaile, to whom a copy of this report, the LIC811 Confidential Names List, the LIC809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.