Incident investigation·November 12, 2024

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent case management visit with the purpose of continuing the investigation into a self-reported incident. LPA arrived at the facility at 12:12PM and was greeted by front desk staff. LPA met with Executive Director (ED) Eden Tolentino at 12:16PM. Entrance interview conducted. An incident report was received at the Woodland Hills Regional Office on 02/12/2024. Incident report indicated that on the night of 02/11/2024, Staff #1 (S1) admitted to another staff that S1 was frustrated with Resident #1 (R1) and that S1 had kicked R1. The document states that the incident was reported to Long Term Care Ombudsman and Ventura County Sheriff in addition to Community Care Licensing and the resident's responsible party. LPA Christine Yee conducted an initial case management visit related to this incident on 02/14/2024 from 10:45AM to 03:05PM. During the initial visit, LPA Yee conducted an interview with Brian Larios, Executive Director at 11:38am, an attempted interview with R1 at 11:26am, telephone interview with Staff #3 at 1:38pm and attempted telephone interviews with S1 at 1:58pm and Staff #2 at 1:21pm. Video camera footage was reviewed at 12:48pm and a copy taken at 1:08pm. Copies of facility documents were collected throughout the visit. LPA Yee was informed that as a result of the incident, S1’s employment at the facility was terminated. During today’s subsequent visit, LPA Dulek conducted an interview with ED Tolentino at 12:20PM, reviewed and obtained copies of relevant documents, and briefly toured the facility with ED at 12:45PM. No immediate health and safety hazards were observed during facility tour. LPA Dulek reviewed recorded video footage of the incident, which shows S1 pulling R1 by their hands and R1 falling to the ground. R1 then raises their feet and kicks at S1, then S1 kicks R1. S1 then picked up R1’s shoe and appears to hit R1 with their shoe before walking away down the hall, leaving R1 on the floor. LPA Report Continued on LIC 809-C Dulek confirmed the facility conducted an internal investigation into the incident and as a result terminated S1’s employment effective 02/13/2024. LPA confirmed S1 is no longer associated to this facility in Guardian. Review of S1’s staff file did not contain additional write ups or performance concerns. The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or CA Health and Safety Code. Failure to correct the deficiency may result in civil penalties. Executive Director was informed that at a later date, civil penalties might be assessed based on health and safety code 1569.49(f). Exit interview was conducted with Executive Director. A copy of today’s report and appeal rights were reviewed and provided.