Incident investigation·June 5, 2025

On June 5, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit in relation to an incident that occured on 5/26/25. LPA met with Assistant Administrator, Gabriel Mendoza and explained the purpose of the visit. The Licensee reported on 5/26/25, Resident 1's (R1's) hand was inside of Resident 2's (R2's) clothes and was not bothered by it according to Resident 3 (R3) who was also the witness. All required parties were notified and facility assessed residents for any signs of injury or distress. During the visit, LPA interviewed the Assistant administrator, reviewed R1 and R2's file, and attempted to interview residents. LPA was unable to interview R2 and R3 as they were eating lunch in the dining hall. LPA interviewed R1 who denied touching R2. Based on file reviewed, R1's physician's report indicates that R1 does not have any cognitive impairments and/or inappropriate behaviors. The assistant administrator indicated that this incident is the first incident that has occurred with R1 being inappropriate to another resident at the facility. Based on R2's file reviewed, R2 has a diagnosis of dementia and does have inappropriate behaviors and is confused/disoriented. According to the assistant administrator, staff immediately intervened when R1 and R2 were observed together and redirected. No incidents between R1 and R2 have occurred since 5/26/25. An in-service training was provided to all staff after this incident. No citations are issued during the visit. Report is reviewed with Assistant Administrator and a copy is provided.