Incident investigation·July 21, 2025

On 07/21/2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident visit regarding an incident that occurred on 07/02/2025 between Resident #1(R1) and Resident #2 (R2), when R1 placed their hand on R2’s left chest. Upon arrival, LPA met with the Executive Director (ED), Li Li. The LPA disclosed the purpose of the visit. The Executive Director (ED) stated that the incident occurred around 12:30 PM in the Memory Care unit. After lunch, team members were focused on assisting residents with toileting and preparing them for their naps. Under the supervision of a full-time activity assistant, only a few residents remained in the activity room. When the caregiver (S1) entered the activity room, they observed that R1 was placing their hand on R2’s chest, inside R2’s clothing, but not making direct skin-to-skin contact. ED stated that after a few seconds, R1 removed their hand on their own. S1 then redirected R1 away from R2 and reported the incident to their supervisor. The charge nurse conducted a physical assessment of R2 and did not observe any scratches, red marks, or injuries. The following day, the incident was reported to the ED, as the ED had been off duty at the time of the incident. ED contacted the Palo Alto Police Department (PD), which took the report over the phone and decided not to respond in person, as there were no physical injuries involved. ED was provided with a police case number. ED further stated that they consulted with the Ombudsman, who indicated that there was no need to file an SOC 341 since there was no physical injury and the contact was indirect. ED notified both R1’s and R2’s physicians. Subsequently, the facility received a change in medication orders for R1 to address anxiety, and R1’s service plan was updated accordingly. Continued on LIC809-C ED stated that R1 was being closely monitored and that an intervention plan was being developed with staff to address how to manage similar incidents in the future. R1 was placed away from female residents during group activities. ED stated that they held a meeting with R1’s responsible persons to discuss the intervention plan and advised them that if R1’s behavior persisted, the facility might no longer be an appropriate setting for R1. ED also stated that they communicated with R2’s family regarding measures in place to keep R2 safe under close supervision and to ensure that R1 would not be seated in close proximity to R2. ED stated that R2 did not recall the incident or whether R1 had touched them inappropriately, and R2 remained at their baseline. R1 also did not recall the incident. ED further stated that staff training was conducted to help team members recognize and appropriately handle sensitive situations. No deficiencies were cited during today's visit. An exit interview was conducted with the Executive Director. A copy of this report was provided to the Executive Director, Li Li, whose signature on this form confirms receipt of the report.