Incident investigation·November 19, 2025

Licensing Program Analyst (LPA) Kontilis conducted a subsequent case management visit to issue final findings on this investigation. Entrance interview conducted. On 11/06/2025, the facility self-reported an incident regarding Staff 1 (S1) and Resident 1 (R1). The report states on 11/04/2025 the SafelyYou camera system alerted facility management about an incident that occurred on 11/02/2025. On 11/18/2025, LPA reviewed the camera footage which showed S1 getting R1 out of bed to provide their medication. The video shows R1 is combative and resistant and R1 slides down the bed. S1 picks up R1 and puts them in a standing position. R1 is again combative and hits S1. While R1 remains seated on the bed, S1 then takes approximately seven steps from the bed to the entrance door, closes the door, then takes approximately six steps back and returns to the resident. S1 grabs R1 by their arm and their back and quickly walks them across the room. R1 appears surprised and distressed by this quick action. R1 loses their balance and falls forward to the floor. S1 picks up R1 off the floor again, then quickly pulls their nightgown off over their head. S1 leaves R1 standing undressed while getting a new brief and changing the brief. S1 again leaves R1 standing while getting new clothes and redressing them. On 11/04/2025, the facility counseled S1 and issued a final written warning for poor caregiving and incorrect technique. On 11/05/2025, corporate reviewed the video and decided the poor caregiving could be interpreted as rough handling and abuse. S1 was terminated as a result. On 11/06/2025, the incident was reported to the appropriate parties. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D). Exit interview conducted. Copy of report and appeal rights issued at the time of the visit.