Incident investigation·January 5, 2024

Licensing Program Analysts (LPAs) Dang Nguyen and Juliana Barfield conducted an unannounced Case Management - Incident visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Suzette Johnson. Today's visit was in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office (received on 12/27/2023), involving Staff #1 (S1) and Resident #1 (R1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. During today’s visit, LPAs performed a facility tour. At the time of the visit, R1 was off-site and unable to be interviewed. However, a welfare check was performed on other residents in care. LPAs also reviewed pertinent care and investigative records and interviewed other relevant residents and staff. According to R1’s latest LIC602 Physician’s Report (dated 10/23/2023), R1 was diagnosed with Dementia. Their doctor stated that while R1 was “confused/disoriented,” R1 was also able to follow instructions and able to communicate needs. According to staff interviews: Multiple managers and caregivers noted that R1 had a tendency towards tactile stimulation, sometimes touching things or others out of curiosity. During the evening of 12/23/2023, R1 touched Resident #2’s (R2) shoulder, which bothered R2. Staff #2 (S2) said they saw S1 slap R1’s arm. S2 reported their concerns about the incident to facility management. In their written statement, S1 said they “grab[bed]” R1’s hand to redirect them away from R2. There were no injuries to either resident. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Per staff interviews, personnel records, and interview of Resident #3 (R3): there was another incident occurring on 12/28/2023, involving S1 and R3. On this date, S1 was speaking on their personal cell phone inside R3’s bedroom. R3 became annoyed and asked S1 to stop. S1 did not, so R3 used their own cell phone to document S1’s actions. When S1 saw this, they physically took R3’s own cell phone away, against their will, to delete the photo which R3 took of them, before returning the phone to R3. R3 said during the scuffle over the phone, R3’s arm brushed up against a wall. R3 stated that they did not believe S1 intended to hurt them, and that S1 was going after their phone, not R3 themselves. LPAs observed that although R3 was diagnosed with Dementia (per their latest LIC602 Physician’s Report dated 12/19/2023), R3 spoke coherently and knew the present year, the present city they were in, the name of the facility, and the name of the current US President. R3 was able to be qualified as a credible witness for this case. R3’s description of incident to CCLD was consistent with the description they earlier gave to Licensee. LPAs observed a very minor scab on R3’s left elbow, which R3 attributed to the incident with S1. According manager interview and personnel records, Licensee’s terminated S1 employment on 01/04/2024, citing S1’s “violation of Resident’s Rights” as one of the reasons. A preponderance of evidence exists to show that Licensee’s staff (S1), through their actions, did not uphold resident dignity and privacy. Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). Plan of Corrections were jointly developed with the licensee. An exit interview was conducted with Johnson, 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 during the visit.