Incident investigation·April 17, 2024

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – incident visit. LPA met with Executive Director, Tina Bagheri. The purpose of the visit is to follow-up on an incident report the Department received on 12/06/2023 regarding resident (R1). On 12/04/2023, it was reported that a staff found R1 with a pair of scissors and minor injury to the body inside his/her apartment. Resident was transported to the hospital for medical attention. R1’s family was informed. Based on interview, the scissors was brought into R1’s apartment located in assisted living during admission. Residents are allowed to have this item based on review of the resident's medical records. If there is any indication these items would pose a risk to the residents, the facility would communicate the concern with family and/or the resident. Prior to the incident R1 did not show any signs of self-harm. After the incident, the staff did a room check and removed all items which could be harmful to the resident and returned all objects that could be harmful to the family member. Based on record review, R1 was diagnosed with a mild cognitive impairment. R1's records did not indicate a risk for self-harm or any inappropriate behavior. After the incident, R1 was provided a private 24/7 companion and is stated to be doing well. The facility conducted a re-assessment and in-service training with staff. Around 4:15PM, LPA and the Executive Director entered R1's apartment. R1 granted permission to LPA to tour R1's apartment. Documents were obtained during visit to include R1's physician's report, preplacement appraisal information, service plan, and in-service training. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Tina Bagheri and a copy of the report was provided.