Incident investigation·May 31, 2024

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - incident visit. LPA met with Executive Director (ED) Rachel Brown. On 05/30/2024, the Department was notified of a serious incident that occurred with resident (R1) and staff (S1). On 05/29/2024 around 9PM, the facility received an alert from their fall detection system from R1's bedroom. The review of the video showed a staff (S1) assisting R1 back to bed in a rough manner. The Executive Director was notified of the incident immediately and S1 was escorted out of the building. Staff was immediately suspended and did not return to work after the incident. After the incident, staff assessed R1 and observed redness on R1's left cheek and scratches on the forehead. Emergency services were not contacted as R1 did not complain of any unusual pain. The facility notified R1's family, Ombudsman, and local law enforcement. On 05/30/2024, in-service training was conducted with staff to include the topics of elder abuse, mandated reporting, and R1's care plan. During visit, LPA interviewed 2 staff members and R1. LPA reviewed the video with ED and recorded part of the video using LPA's state issued cellular device. LPA requested the video footage from the facility's fall detection system to be sent via email. Documents were obtained to include the law enforcement case number, in-service training records, and S1's personnel file. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Rachel Brown and a copy of the report was provided.