Incident investigation·October 17, 2022

On October 17, 2022, Licensing Program Analyst (LPA) Komal Charitra and Licensing Program Manager (LPM) Cara Smith conducted an unannounced case management visit to follow up on a visit made on October 10, 2022. LPA and LPM met with Director of Health Services (DHS), Amyda Astrero and Administrator, Robert Snee, joined shortly thereafter. LPA explained the purpose of the visit. On October 10, 2022, LPA conducted a case management visit to follow up on an un-witnessed incident that occurred on September 25, 2022 where Resident #2 (R2) was screaming and agitated and verbalized Resident #1 (R1) touched R2's breast and shook it. During the visit, LPA Charitra and LPM Smith toured the facility with DHS, Amyda Astrero and observed R1 sleeping in bed with his/her one on one caregiver in the room. LPA and LPM reviewed R1's file and needs and service plan. In addition, LPA Charitra and LPM Smith interviewed DHS and Administrator regarding R1. According to the Administrator and DHS, R1 has a new Geriatric doctor that has been in communication with the facility. In addition, it was indicated that R1 is on new medications prescribed by the new doctor. According to the file reviewed, R1 was admitted to the facility on May 3, 2022 and this incident is his/her fifth incident at the facility, three of which are of R1 displaying inappropriate behaviors towards female residents. In addition, based on R1's needs and service plan, R1 has a history and pattern of aggressive and inappropriate behaviors towards residents. Although facility has interventions in place, R1 has re-occurring incidents. 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 Director of Health Services (DHS), Amyda Astrero and Administrator, Robert Snee, and a copy is provided with appeals rights.