Incident investigation·November 17, 2022

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Valerie Alves, Care Center Administrator. The purpose of the visit was to inquire about an incident self-reported by the facility on 11/01/2022 that occurred on 10/29/2022. The incident involved a family member of resident R1 observing staff S1 sitting down watching television in the common area. At the same time, the family member observed R1 to be sitting in bed attempting to put on clothes and had soiled briefs in the bathroom. The facility report states that the facility provided verbal disciplinary action for S1 and also conducted in-service training for staff to make frequent rounds to attend to residents and ensure their cleanliness. During visit, LPA Marrufo obtained copies of S1's written disciplinary record regarding the incident as well as the training log for the in-service training that was conducted. In the written disciplinary record, staff S1 admitted to be sitting down watching television while R1 was in the bedroom alone. During interview, Valerie Alves stated that the facility staff have been told that the television should not be put on any channel that is not meant for the residents to watch, the radio should be playing music intended for the residents if the television is not being used, and that the staff should never be on their telephones while working. The staff have also been told to ensure the cleanliness and safety of residents and to conduct frequent rounds with the residents. LPA Marrufo reviewed R1's care plan, which states that R1 needs hands on assistance with dressing. A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D for more information. This report was reviewed with Jose Toribio, Director of Staff Development and a copy of the report and appeal rights were provided.