Incident investigation·January 18, 2024

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator Li Li. The purpose of the visit was to follow up on an Incident Report and Suspected Adult/Elderly Abuse Form (SOC341) submitted by the facility to CCL on 10/25/2023. The Incident Report and SOC341 stated that resident R1 had a witnessed fall on 10/22/2023. The reports stated staff S1 claimed that staff S2 did not report the truth when reporting the incident to R1's family member (FM1). The reports also state that S1 quit from being employed at the facility and left the facility. During visit, LPA Marrufo interviewed staff S2, FM1, and staff S3-S8. LPA Marrufo conducted an attempted interview with R1 and observed R1. S3 stated during interview to have assisted R1 when R1 was walking, but R1 began walking quickly and R1 fell face first in the facility hallway. S3 stated to have reported the incident to a nurse and medication technician at the time of the fall and observed staff reporting the fall incident to FM1. S3 stated FM1 arrived at the facility and S3 showed FM1 how R1 fell. During interview, S2 stated to have not neglected R1. S2 stated to have reported to S2 about R1's fall as well as what S2 found in S2's assessment of R1. FM1 stated during interview to not believe that staff were withholding information about R1's fall. Staff S4-S8 stated during interview to have not observed any incidents of staff neglecting residents. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Li Li and a copy of the report was provided.