Incident investigation·August 28, 2024

On 8/28/2024, Licensing Program Analyst, Tobola arrived unannounced for the purpose of conducting a case management to follow up on a facility self-reported incident and was greeted by Executive Director, Fili Igafo. The incident occurring on 6/7/2024, involved morning staff observing a table that was blocking resident’s (R1) bedroom door. The incident was reported to CCLD by the facility and confirmed based on the report and staff interviews with LPA Calandra, that overnight caregiver staff (S1) intentionally placed table in front of R1’s door to prevent R1 from wandering. LPA Calandra previously gathered information on the incident and spoke with Executive Director on corrective actions. LPA Tobola was informed that the facility had conducted an internal investigation and terminated staff (S1). Due to resident R1's door being obstructed intentionally by staff, the facility has failed to ensure residents room door were unobstructed and violated the personal rights of resident R1. 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.