Incident investigation·February 24, 2022

On February 24, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit regarding an Incident Report. LPA was greeted by the Director of Resident and Family Services, Diane Sapienza-Boundy, and the Director of Health Services, Glynis Marcantel, joined shortly thereafter. LPA Charitra explained the purpose of the visit. The licensee reported that on January 19, 2022, two residents were involved in an unwitnessed altercation. The staff walked into the library and saw a resident on the floor (R1). Another resident (R2) was trying to make a phone call and Resident (R1) attempted to grab the receiver. Somehow R2 hit R1 with the receiver. During the case management, LPA observed R1 being changed in her bed and R2, in the dining hall watching television. LPA interviewed staff and reviewed both resident’s files. According to the files reviewed and the documentation collected indicates that R1 has a diagnosis of Dementia with behavioral disturbances while R2 has a diagnosis of Alzheimer’s and Pseudobulbar. This is the second altercation involving R1 without any staff being present since November 2021 (see LIC809 dated 11/15/2021). In November was reported that staff had left R1 and another resident alone in the dining room, and when staff walked in observed that R1 was kicking the other resident. The report of January 19, involving R1 and R2 noted above, indicate that there was no staff member around or physically present in the library supervising the residents. The licensee has indicated that no one-on-one supervision is provided unless it is paid by the resident; however, Regulation requires the licensee to provide sufficient staff to meet the residents’ care and supervision. In the above incidents, there was an absence of supervision resulting in altercation between residents. Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page. Report is reviewed with Glynis Marcantel and a copy will be provided.