Incident investigation·February 14, 2024

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Health Services Director Brittany Blaul. Today's visit was in response to two (2) SOC341 Reports of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office (received on 12/07/2023 and 02/01/2024, respectively). Per the first SOC341: it was alleged that Resident #1 (R1) had around $300 in cash stolen from their wallet sometime between 11/21/2023 and 12/06/2023. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] Per the second SOC341: R1 had another $250 in cash stolen from their wallet sometime between 01/29/2024 and 01/31/2024. During today’s visit, LPA performed a brief facility tour and collected copies of and reviewed pertinent care and personnel records, visitor logs, theft logs, and investigative notes. LPA also interviewed relevant staff. R1, who was a hospice care patient, passed away on 02/09/2024 and was unable to be directly interviewed by CCLD. Regarding the first theft incident (i.e., $300) against R1, records and staff interviews showed: Licensee learned of the cash loss from R1’s responsible person (RP). Licensee timely reported the loss to CCLD, the Long-Term Care Ombudsman Program (LTCOP), and local police (CVPD). Per manager interview, Licensee’s internal investigation involved interviewing R1, who at that time, was of sound mind and a reliable historian. R1 told Licensee that they clearly saw Staff #1 (S1) take $300 in cash from their wallet. A review of personnel records showed that Licensee ended S1’s employment on 12/15/2023 for an unrelated reason, per the written termination notice. However, manager interview revealed that R1’s testimony about the first theft incident was a contributing factor towards R1’s termination of employment. The facility’s LIC9060 Theft and Loss Record corroborated that one of the “Action[s] Taken / Follow Up” for the first theft incident against R1 included “term of employee.” [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Regarding the second theft incident (i.e., $250) against R1, records and staff interviews showed: Licensee learned of the cash loss from R1’s RP. Licensee timely reported the loss to CCLD, LTCOP, and CVPD. Per manager interview: Licensee’s internal investigation involved interviewing R1, outside sources, and facility frontline staff who were assigned to R1 during the date range of the loss (which was after S1 was no longer working at the facility). Interviews of frontline staff did not reveal any breakthrough in the second case. R1 by the date of the second investigation was less alert, as they were nearing end of life. Manager interview, corroborated by hospice visit notes and the facility’s visitor log, showed: During the date range of the second loss, R1 was visited inside their bedroom by multiple outside personnel, to include hospice agency staff and durable medical equipment (DME) company staff. Hospice notes showed R1 was asleep during at least two of these visits. A preponderance of evidence exists to show that on at one occasion, Licensee’s staff (S1) did not ensure that a resident in care (R1) was protected from theft or loss. One (1) deficiency was cited per California Code of Regulations, Title 22 (see attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. LPA also issued one (1) Technical Violations (TV) per California Health and Safety Code, regarding delayed-egress door signs (see LIC 9102-TV page). An exit interview was conducted with Blaul, to whom a copy of this report, the LIC809-D page, the LIC9102-TV page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.