Incident investigation·April 7, 2023

Licensing Program Analyst (LPA) Albert Johnson arrived at facility to conduct a Case Management visit due to multiple incidents involving aggressive acts resulting in a death, aggressive acts resulting in a resident hitting another with a fire extinguisher. Based on records reviewed and incidents which resulted in a death and bodily injury, the department is requesting that the facility increase the staffing to address the lack of supervision which has resulted in these unfortunate incidents including a death. LPA was able to determine that the facility has reduced the number of staff on the AM shift from eight staff to seven staff and the same for the PM shift from eight to seven. The NOC shift was staffed at four and now staffed at three. As a result of this reduction in staffing the facility has compromised the safety of the residents in care. On 2/13/2023 R1 was assaulted by R2 resulting in R1 going to the ER for evaluation. The discharge summary diagnosed "Assault and back Pain. R1 has since moved out of the facility. Continued The service plan for R2 has not been updated to address the assaultive behavior. On 3/4/2023 R3 was assaulted by R4 resulting in R3 going to the ER for evaluation. R3 was placed on comfort care, due to a brain bleed and stroke. R3 passed away in the hospital. The service plan for R4 has not been updated to address the assaultive behavior. Both incidents were reported to the Stockton Police department and a Report of Suspected Dependant Adult /Elder Abuse report was submitted as required. Per California Code of Regulations, Title 22, the following deficiencies and immediate civil penalty have been issued. The circumstances of these incidents are being evaluated for additional civil penalties. Exit interview.