Incident investigation·August 19, 2025

On 8/19/2025, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management-incident. LPA met with Executive Director (ED) Cleitus Jones and explained the purpose of the visit. The visit is regarding about the SOC 341 submitted by the facility to Licensing. On 8/12/2025, a resident (R1) was restrained to his/her wheelchair with a gait belt by two staff members. Another staff member (S2) who witnessed it immediately removed the restraint. The two staff members were interviewed and admitted to using the belt to prevent a fall as said resident was restless. Facility has since terminated the two staff members. LPA interviewed S2 and he/she stated that the incident was reported to her by another staff (S1). S2 checked R1 and there were no injuries or bruises. LPA also interviewed S1 and he/she mentioned that when he/she saw R1 with a gait belt, he/she removed it right away and told the two staff members to not use the restraint. ED has also mentioned that there is an overlap of staffing as the night shift were still working around the time of the incident. Facility conducted an in service training for staff regarding the risks of restraining a resident and reporting requirements, after the incident happened. Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Report is reviewed and a copy of the report and appeals rights are provided.