Follow-up on corrections·November 13, 2025

On 11/13/2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to deliver the finding of an incident that was reported by the facility. LPA met with administrator, Brian Raimundo and explained the purpose of today's visit. On 10/9/2025, the facility reported that staff #1 (S1) witnessed staff #2 (S2) and staff #3 (S3) holding resident #1 (R1)'s arms down in bed while forcing R1 to take medicine. LPA attempted to interview R1 and R1 did not remember the incident and was not able to answer LPA's questions due to R1's diagnosis. LPA interviewed S1 who stated that on the day of the incident, she was working on the Assisting Living Unit and was called to assist the Memory Care Unit. When she got off the elevator, she heard R1 screaming in the room and when she got to the room, she witnessed S2 and S3 were holding R1's arms while forcing R1 to take the medicine. LPA interviewed S2 who stated that on the day of the incident, R1 did not want to take the medicine and R1 was attempting to hit S3 while S3 was trying to give the medicine so S2 assisted S3 by holding down R1's arms while R1 was in bed. S2 stated that R1 needed to take the medicine so R1 would not hit other people. LPA requested to interview S3 but S3 did not return call. LPA interviewed the memory care director who stated that she was not at the facility when the incident happened but when she was informed on the next day, she reported it to the Regional Director of Operations and both staff were placed on administrative leave. LPA interviewed the current administrator who stated that he was not the administrator when the incident happened but he was informed by the Regional staff that S2 and S3 were terminated. Based on training records, the facility provided an in-service on 10/8/2025 on Medication Pass and the training material indicated that resident shall not be forced to take medication, but the staff sign-in record did not indicate that S3 attended the in-service. After the investigation, this incident is substantiated as R1 has the Right to receive or reject medical care or other services. Based on interviews, observation, and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation was determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with administrator and a copy is provided with Appeal Rights.