Incident investigation·January 2, 2026

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit.  LPA was greeted by and met with Executive Director Calais Anguiano, to discuss the purpose of the visit. Today's visit is in response to the facility's self report regarding Staff 1 (S1) utilizing an unauthorized self-release restraint on Resident 1 (R1) during incontinence care. Staff interviews, written staff statements, and facility documentation of the incident revealed that the facility had a "no restraint" policy, which was trained to all employees, including S1. The facility conducted an internal investigation regarding the incident; S1 informed that the intent of the restraint was to keep R1 from scratching themselves due to agitation while being provided care. Upon observation of the restraint by other staff, the situation was elevated to management and S1 was suspended immediately and subsequently terminated. An immediate medical examination was conducted for R1 by a licensed medical professional where no signs of trauma or injury were assessed for R1. All required parties were informed of the incident per reporting requirements. The investigation showed that the situation was elevated per the facility's chain of command and management took immediate action to rectify the incident. The investigation additionally revealed that the facility provided sufficient training to staff regarding appropriate postural support use and the prohibition of unauthorized restraints. S1 admitted knowing the facility's policy against use of restraints. LPA conducted a health and safety check for R1 at the facility; no health or safety issues were identified. A deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D).  A Plan of Correction was jointly developed with the Executive Director. An exit interview was conducted with Executive Director Calais Anguiano, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. Their signature confirms receipt of these documents.