Incident investigation·August 1, 2023

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case manager – incident visit. LPA met with Executive Director (ED) Ignacio Lopez. On 07/19/2023, the Department received an incident report for resident (R1). On 07/04/2023, staff (S2) attempted to redirect R1 out of the kitchenette area and R1 became agitated. Staff (S1) attempted to assist in redirection and R1 became more combative. During the incident, it was observed by staff (S3) that S1 pinched R1’s nose. S1 stated it was because R1 bit him/her. During visit, LPA interviewed 3 staff members and 2 witnesses. Based on interview, it was observed S1 pinched and twisted R1’s nose. It was observed R1 had bleeding on the nose due to a scratch. 2 out of 2 staff state there was no observation R1 had bit S1’s finger nor any indication of a bite mark. The incident was reported to the facility management and placed S1 on leave during an internal investigation. On 07/16/2023, S1 was terminated from the facility. After the incident, the facility notified R1’s physician, notified R1’s family , and conducted an in-service training on topics to include but not limited to resident risks, radiance introduction, observation, protocol for change of conditions, mandatory reporting, incident reporting and investigations, and preventing/recognizing/reporting abuse. ED states the training on proper re-directions were covered during the training. Based on interview and record review, the ED faxed the incident report and SOC341 to the Department on 07/10/2023. The facility received a fax cover sheet with the note of “memory busy”. SEE LIC809-C. The ED denied notifying the Department of the incident via telephone nor attempted to re-send the incident report through another mean. The incident report and SOC341 was re-faxed successfully to the Department on 07/19/2023. LPA advised the ED and provided an alternative method to submit incident reports going forward. During visit, it was observed staff members were not associated to the facility. The facility was licensed as of 06/13/2023. LPA showed the facility’s personnel summary to the ED. The ED stated the individuals listed on the personnel summary work in the home office. The ED stated the staff obtains criminal record clearance as they are staff who also work at another licensed facility under the Licensee. The ED states to have assumed all personnel were transferred from the other care facility during the pre-licensing application process. LPA advised the ED and ED stated understanding. ED attempted to associate staff via Guardian, however, encountered technical difficulties. The ED began filling out the LIC9182s to associate staff members to the facility. The ED states to complete the forms and to submit them to the Department, ASAP. A deficiency is being cited per California Code of Regulations, Title 22. Advisory note provided. This report was reviewed with Executive Director, Ignacio Lopez and a copy of the report and appeal rights were provided.