Incident investigation·May 23, 2025

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Executive Director (ED) Meghian Geul. The purpose of today's visit is to follow up with the case management visit conducted on 5/7/2025. On 5/2/20254, the Department received an incident report from the facility that an incident between resident R1 and resident R2 occurred on 4/29/2025 at the facility. On 5/7/2025, LPA interviewed ED, 2 residents (R1, R2) and 2 witness staff (S1, S2). LPA requested physician reports and service plans of resident R1 and R2. Based on the interview and review of incident report, on 4/29/2025, around 2:00PM, in the activity room, resident R1 was walking by the chair which resident R2 was sitting on. R2 suddenly pushed R1 with no reason and R1 fell on the ground. Caregivers and Med Tech separated R1 and R2 immediately. Caregiver S1 was on site to help residents during the activity and staff S2 conducted the activity in the activity room. Both S1 and S2 stated there was no altercation between R1 and R2 prior the incident. This is the first incident between R1 and R2. The facility updated the care plans of R1 and R2. Staff training of abuse prevention and managing aggressive behavior has been provided to staff on 5/2/2025.. Continue on LIC809-C. Page 1 of 2. Based on the review of physician reports of R1 and R2, R1 has no aggressive behavior and R2 has verbal aggressive behavior. No citation was issued today. Exit interview was conducted with ED. The report was provided to ED for review and signature. A copy of the report was provided to ED.