Incident investigation·March 19, 2025

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management - Incident visit and met with Senior Executive Director (ED) Radhika Martinez. On 3/19/2025, the Department received a report that a staff (S1) had an inappropriate behavior to a resident (R1). The purpose of today's visit is to obtain more information and to investigate. LPA interviewed ED, 6 staff (S2 - S7), 5 residents ( R1 - R5), and a family member (FM) of a resident. ED stated staff S1 was terminated by the facility because S1 was found sleeping while on duty. ED stated this is the first incident of S1 regarding inappropriate behavior. ED stated there is no witness for the incident. 6 Out of 6 staff stated they never saw S1 had inappropriate or aggressive behavior. R1 stated this is the first time that S1 had this kind of behavior. 1 out of 5 residents does not remember S1. 3 Out of 5 residents stated they did not see S1 had inappropriate or aggressive behavior. LPA requested R1's physician report, appraisal needs service plan. LPA obtained the facility staff training document regarding resident abuse and reporting requirement. This case needs further investigation. 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.