Incident investigation·January 8, 2025

On 01/08/24, Licensing Program Analyst Renee Campbell arrived to the facility unannounced to complete an annual inspection. LPA Campbell met with Valerie Pais, Administrator (7018063740) and explained the purpose of the visit. Upon entry, LPA Campbell observed a client playing the piano for other residents who complimented their skill. Staff welcomed LPA Campbell to the facility and directed them to sign in and for a digital fever check. On 12/30/24, an Unusual Incident Report (UIR) was received regarding a possible sexual assault that occurred. On 12/28/24 staff responded to R1’s cries for help from their room and their room alarm. Staff 1 (S1) found R1 laying on the bed with R2 on top of them. While R2 was assessed at the hospital, there is no report of medical care for R2. Because the UIR does not clarify if there was an attempted sexual assault, LPA Campbell conducted a case management. When contacted, R1’s responsible party (R3) reported that R2 had many incidents of attempting to go into R1’s and other residents’ rooms and lay on their beds or stare out their windows. On the day of the incident on 12/28/24, when R3 arrived, R1 had fallen asleep and R3 refused further medical care. R3 reported that R1 did not remember the incident and R3 did not believe R1 had been sexually assaulted. Per S2, when R2 attempted to strangle a staff member. The facility then sent R2 to the hospital for reassessment and prepared to submit an eviction request to licensing. However, before that occurred, the hospice case worker found a new placement. R2’s family then came and removed his belongings the next day. R2 was removed soon after this incident due to violent outbursts with staff. Before R2's removal, the administrator consulted with licensing staff and attempted to change medication, care plans and use 1 on 1 care. Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted with Valerie Pais, Administrator, and a copy of this report was provided.