Incident investigation·October 2, 2024

Licensing Program Analyst (LPA), Carmen Lopez, conducted an unannounced visit to initiate a case management visit. LPA Lopez identified herself and was granted entry by concierge Jeffrey Keast. LPA Lopez stated the purpose of the visit and reviewed the basic elements of the visit with Executive Director Marivel Johnson and Administrative Specialist Sabrina Pegross. This visit was in response to an Unusual Incident/Injury Report (IR) that was received at the San Diego Regional Office on September 20, 2024. The IR stated that there was an incident that transpired on Wednesday, September 18, 2024, with resident #1 (R1) who mentioned that they were assaulted but no person was identified. The facility made proper notifications to law enforcement, Long Term Care Ombudsman (LTCO), residents responsible party and to the Department. During today's visit LPA Lopez briefly toured the facility, spoke with staff and R1, and requested and obtained relevant documents pertinent to this incident. LPA Lopez verified R1 had delusions when the allegations were made. According to records R1 does have an underlining condition of hallucinations. Additional records showed that R1 was diagnosed with an infection which altered R1's behavior and baseline. LPA informed Executive Director Marivel and Administrative Specialist Sabrina Pegross that there may be possible follow-up telephone calls or visits for this incident. No deficiencies were cited during today’s visit. An exit interview was conducted with Executive Director Marivel Johnson and Administrative Specialist Sabrina Pegross, and a copy of this report, LIC811 and Licensee Appeal Rights (LIC9058) were provided at the conclusion of the visit. The signature below confirms that the documents were received.