Incident investigation·July 31, 2025

On July 31, 2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident inspection visit regarding a reported Theft and Loss incident that occurred on 07/17/2025. The facility also reported SOC 341 for the same Theft and Loss incident. Upon arrival, the LPA met with the Executive Director (ED), Li Li and disclosed the purpose of the visit. The ED informed the LPA that the total facility census was 184. ED stated that during a care conference, R1 reported that four art pieces were missing. These pieces were originally stored in R1’s closet, wrapped in a blanket. They were only paper art pieces and had not yet been placed in frames. The DPOA, who attended the meeting, brought copies of similar art pieces to show, but they were not the original items. The DPOA stated that R1 purchased the art pieces at a street fair for $40 each, totaling $160 for all four pieces. The ED asked the DPOA if they had thoroughly searched R1’s room, and the DPOA confirmed that they had. ED also asked if the large off-site storage unit rented by R1 had been checked, as the DPOA frequently moved R1’s belongings between the room and the storage space. The DPOA stated they did not recall checking the storage unit. No missing art pieces were found in the room. The DPOA stated that R1 had a history of hiding items and had been treated by a neurologist for paranoia and high levels of anxiety, which contributed to hoarding and hiding behaviors. R1 insisted that the four art pieces had been hidden very well in the closet. ED stated that R1 believed that a staff member had taken the art pieces while R1 was out of the room, particularly in May 2025, when the flooring in R1’s room was being replaced and R1 temporarily stayed in a nearby room. R1 stated it must have been a woman, but could not identify who. Continued on LIC-809C ED reassured R1 that staff had not touched anything in the closet and had not replaced the flooring under the closet. ED requested permission from both R1 and the DPOA for staff to search the room for the missing art pieces, and both agreed. After the meeting, staff searched the room but did not locate the missing art pieces. ED informed R1 and the DPOA that the police would be contacted to report the incident as a theft and loss, and they agreed. ED stated that R1 had expressed multiple times that they were satisfied with the investigation conducted regarding the missing art pieces and felt safe residing at the facility. The DPOA stated that the facility remained the appropriate place for R1 and confirmed that they would be the only person to move any items from R1’s room. ED contacted the police and was advised that, due to a lack of evidence, the incident should be filed online. ED submitted the report online, provided R1 with a copy of the police report and case number, and informed DPOA that R1 had a hard copy. ED also filed reports with the Ombudsman and CDSS. ED stated that an in-service training was conducted with staff regarding residents’ rights, property protection, respecting personal space and belongings during care tasks, and elder abuse prevention. ED documented that R1 had waived declaring personal items on the inventory list at the time of admission. Theft and loss records were logged on LIC 9060. LPA reviewed R1’s LIC 602 Physician’s Report, Needs and Services Plan, and LIC 621 Resident Personal Property and Valuables (SPV) form. LPA observed that no personal property or valuable items were declared; the form was crossed out with “N/A” written and signed by R1. LPA attempted to visit R1's room but caregivers were in the middle of assisting R1 in the transfer to the bathroom for toileting and showering. No deficiencies were cited during today's visit. An exit interview was conducted with the Executive Director. A copy of this report was left with the Executive Director, Li Li, whose signature on this form confirms receipt of the report.