Incident investigation·December 19, 2023

On December 19, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that occurred on December 10, 2023. LPA met with Administrator, Robert Snee and Director of Health Services, Amyda Astrero and explained the purpose of the visit. On December 10, 2023, the Licensee reported that a staff member observed Resident 1 (R1) and Resident 2 (R2) in the room together. It was reported that R1 was touching R2's chest area. R1 has a 24/7 one-on-one private caregiver assigned to him/her, however during the time of the incident, the private caregiver went to use the restroom and left R1 unattended without telling a staff member. During the visit, LPA reviewed R1's file, interviewed administrator and director of health services. According to Administrator and Director of Health Services, agency caregivers are required to contact the nurse's station and notify a staff member prior to going on break/lunch so a staff member can be assigned to be R1's companion while the agency caregiver is on break. Based on R1's file, this is the the third incident involving R1 touching another resident inappropriately; previous incidents occurred 11/7/2023 and 11/8/2023. A 24/7 private agency caregiver was assigned on 11/8/2023. Facility was unable to provide LPA an orientation checklist or training provided to the private one-on-one agency caregiver regarding breaks/lunches. Based on documents reviewed and interviews conducted, facility failed to provide orientation/training to the private on-on-one agency staff member assigned to R1 which resulted to R1 being left unattended. Nevertheless, due to R1 being left unattended, R1 was observed in the room with R2 touching his/her breasts. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in additional civil penalties. Report is reviewed with the administrator and a copy is provided with appeal rights.