Incident investigation·February 28, 2023

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by and identified himself to Concierge Dareen Mattie. LPA then met and explained the purpose of the visit with Business Office Director Mayra Rodriguez and Compass Rose (Memory Care) Director Eva Amorim. Today's visit was in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the San Diego Regional Office on 02/10/2023. According to the report, management recently learned about two incidents from their caregivers: a) there was a night Staff #1 (S1) yelled at Resident #1 (R1) to go to bed and turned off the television (which R1 was watching), causing R1 to become “visibly upset,” and b) there was a day S1 yelled at R1, “berated” R1 for having a moment of incontinence, and physically checked R1’s briefs in a common area in front of other residents. [See LIC 811 Confidential Names List for a description of person identifiers used in this report.] During today’s visit, LPA performed a facility tour / welfare check, collected records, and interviewed R1 and staff. CCLD verified that R1 was physically unharmed/uninjured. Due to their baseline disorientation and memory loss, R1 was not able to participate as a reliable historian in this investigation. According to their latest LIC602 Physician’s Report, R1 was diagnosed with dementia. According to staff interviews and personnel records: upon learning of the allegations, facility managers put S1 on administrative leave pending internal investigation. Per licensee’s internal investigation: S1 denied the allegations. However, there were at least three co-workers who corroborated each of events described in the above SOC341 report. Witnesses revealed that S1's actions made R1 cry. According to interviews and personnel records: Licensee terminated S1’s employment on 02-09-2023 as result of their investigation. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Deficiencies are 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 Rodriguez, 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.