Incident investigation·December 6, 2024

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – incident visit. LPA met with Health Services Director, Jocelyne Bailon. The purpose of the visit was to follow-up on a physical abuse incident that occurred at the facility the night of 12/02/2024. On 12/03/2024, the Department was informed of an incident that occurred between staff (S1) and resident (R1). On 12/03/2024, the community was made aware that R1 was treated in an aggressive manner by S1 the night of 12/02/2024. The incident was captured on the facility's fall detection video system. After the community was made of the incident, S1 was escorted out of the building on 12/03/2024. S1’s employment was terminated on 12/04/2024. The facility also conducted an internal investigation with all the staff involved and who have witnessed the fall detection video footage. On 12/04/2024 and 12/05/2024, the facility conducted an in-service training with all staff (AM/PM/NOC) to include topics of understanding the importance of “see something say something”; mandated reporters; the steps to take to ensure residents safety and well-being; and understanding resident rights. HSD states the training also included proper intervention and techniques for redirection, de-escalation, and dementia. Documents were obtained to include the in-service training sheet/materials and 4 staff member’s job application. A copy of the fall detection video was provided to LPA Dolores via a USB stick. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Health Services Director, Jocelyne Bailon and a copy of the report was provided.