Incident investigation·November 6, 2024

Licensing Program Analysts (LPAs) Christine Dolores and Santino Fortes arrived unannounced to conduct a case management – incident visit. LPA met with Executive Director, Rachel Brown. The purpose of the visit is to follow-up with a SOC341 the Department received on 10/28/2024, based on an incident that occurred with resident (R1) and 10/27/2024. On 10/27/2024, it was reported that during breakfast a staff (S2) exited the dining room area and observation an interaction with S1 and R1. It was observed that S1 approached R1 from behind and grabbed R1's arms by the wrist for approximately 15 seconds. R1 was observed struggling against S1. S2 called S1 over and the interaction ended. R1 was assessed and R1 did not show any signs of injury to include bruising around the area. R1 was unable to recall the incident. During visit, LPAs interviewed the ED and R1. Based on interview with the ED, S1 was terminated following the incident. R1's family members were informed of the incident and police was notified the following day. Based on interview with R1, R1 states all the staff treats the resident nicely and denied a staff hurting the resident. Documents were obtained to include the staff schedule for 11/06/2024 and 10/27/2024, R1's physician's report and service plan, S1's job application, annual confirmation statement, training and the police report number. 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.