Incident investigation·April 14, 2021

On April 14, 2021, at around 1:45pm, Licensing Program Analyst (LPA) Michael Garcia conducted an unannounced case management tele-inspection in response to an incident that the facility had self-reported between Resident 1 (R1) and Staff 1 (S1). Due to COVID-19 pandemic, the inspection was conducted remotely, via video call, with Maria Jereline Madeloso, manager. Today, LPA conducted records review and interviewed Maria and Staff 2 (S2) about the incident. Maria shall ensure to email the following documents to LPA within 24 hours of this report: - April 10, 2021 Unusual Incident Report regarding S1 and R1. - April 2021 staff schedule. - R1’s most current Physician’s Report. - Current resident roster. - S1 training records regarding rights of residents for the past year. - Caregiver notes regarding the incident. Report was reviewed and discussed with Maria at the end of the tele-inspection. An electronic copy of the report was emailed to Maria for signature.