Incident investigation·July 28, 2021

On 07/28/21, Licensing Program Analyst (LPA), Mohamed Filouane, conducted a Case Management visit at the facility with Executive Director (ED) Angela Boucher Tunin, regarding an Incident Report received by the Community Care Licensing Division on 7/27/21. The incident involves a female resident (R1) and a male caregiver (C1). LPA Filouane reviewed the information reported on the Incident Report. The facility's investigation is currently ongoing. In an interview with the ED, LPA Filouane clarified the information reported on the Incident Report. The incident occurred on 07/26/21, when another caregiver (C2) had entered the Memory Care unit of the facility. It is reported in the Incident Report and in an interview with the ED that C2 opened the restroom door and witnessed C1 with their back turned, hands raised, and their trousers down to their knees with their underpants still raised, standing close towards R1. R1 was leaning against the restroom sink with their hands on their side. R1 wore only a bathrobe. It is reported that after C2 witnessed that C1 was undressed with a resident, C2 had went to inform a Medical Technician on duty. The Medical Technician then arrived at the restroom in the Memory Care unit and witnessed the resident unclothed and C1 showering the resident. The Medical Technician reported the incident to the Executive Director, who instructed C1 to leave the facility pending investigation. The Executive Director states that on the same day of 07/26/21, after the ED had instructed C1 to leave the facility, C1 was found in a resident's closed room with R1 and another resident. The Executive Director made their way to the room and estimates that C1 was in the room with R1 and another resident for less ten minutes. According to the ED, the ED asked what C1 was doing in the room, and C1 stated they were telling R1 that they were leaving. San Francisco Police Department arrived at the facility on 07/26/21 and interviewed the resident. Facility management interviewed the caregiver and Medical Technician. LPA requested physician reports of two residents, documentation of facility interviews with staff members, and will contact SFPD for the police report and R1's hospital visit results. Exit interview conducted with Executive Director. This report will be emailed to the Executive Director.