complaint·February 24, 2025

The Department received video footage that corroborated the incident that occurred on, June 10, 2024, at 8:12 AM. The video footage revealed R1 and R2 in a physical altercation. Video footage depicted R2 punching R1 several times in the abdominal area and subsequently throwing R1 to the floor. Staff were summoned by a resident and assessed R1 and R2. A 911 call was initiated at 8:24 AM, and R1 was transported to a local hospital. Law enforcement was contacted and R2 was removed from the facility on a 5150-hold due to danger to others. The Department has investigated the allegation that Neglect/Lack of Supervision resulted in serious bodily injuries and has found that based upon record review, video recordings, and interviews, the licensee did not conduct a reappraisal of R2 to determine if the facility was appropriate placement after R2 exhibited multiple aggressive behaviors towards staff and residents. Therefore, the preponderance of the evidence standard has been met and the allegation is deemed substantiated. This deficiency is noted on the attached 9099-D and is cited in accordance with the California Code of Regulations, Title 22. An immediate $500 civil penalty was assessed, and a plan of correction was jointly formulated with Executive Director Mike McCoy. Per Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Program Administrator of the Community Care Licensing Division. An exit interview was conducted and a copy of this report, LIC 421IM, LIC 811, along with Licensee/Appeal Rights (LIC 9058 03/22) were provided to Mike McCoy at the conclusion of the visit. Review of R1’s physicians report, dated July 19, 2023, revealed R1 has a diagnosis of dementia without aggressive behaviors. According to R1’s pre-appraisal, dated July 28, 2023, R1 uses a walker to ambulate through the facility. Review of R2’s physician’s report, dated May 14, 2024, revealed R2 had a diagnosis of Alzheimer’s Dementia, and had occasional aggressive behavior and confusion. Review of R2’s facility progress notes revealed multiple occurrences of aggressive behavior towards staff and residents after admission. Review of R2’s progress notes revealed on May 25, 2024, the day following their admission to the facility, R2 was in a physical altercation with Staff #5 (S5), resulting in R2 pushing staff up against the wall by the shoulders with full force. R2 then entered a resident’s room and began pushing the resident. Staff redirected R2 away from the resident. On May 28, 2024, R2 was observed going in and out of a resident’s room and pushing them out of their way. On June 3, 2024, while staff were assisting a resident, R2 entered R3’s room and pushed Staff #13 (S13). When S13 tried to redirect R2, R2 became agitated and attempted to tackle S13. On June 6, 2024, R2 entered R3’s room and became aggressive with R3, but Staff #8 (S8) was able to redirect R2. During the incident, R2 squeezed S8’s hands. On June 9, 2024, R2 displayed aggressive behavior by walking up to staff and hitting their fist into their hands. Record review revealed that after multiple occurrences of aggression displayed by R2, a reappraisal was not conducted to reassess R2’s needs or compatibility with other residents. Facility progress notes and medical records revealed that R2 was prescribed as needed medication for agitation and anxiety. Interview with Staff # 7 (S7) revealed a request was sent to R2’s physician for medication adjustments but denied receiving an updated prescription. Review of medical records revealed that the request was received on May 28, 2024, and medication adjustments were made by the physician, but delays occurred with an outside pharmacist. Interviews with 12 staff members were conducted (S1-S12). S1 – S3 reported that R1 and R2 were present in the Sea Breeze dining room when R2 assaulted R1. Interviews with S9 revealed that on June 8, 2024, R1 and R2 had previously been in a verbal altercation where R2 made verbal threats against R1, and staff had to separate them for their safety. Interviews with S4 and S5 corroborated the physical altercation that occurred on June 6, 2024, where R2 entered a resident's room and became aggressive with staff. The Department attempted to interview R1 and R2 but was unable to qualify them due to their cognitive state. [Continued on LIC9099-C]