Incident investigation·September 22, 2023

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management - Incident visit to the facility. The LPA was greeted by Staff Catalina Gonzalez and informed them of the reason for the visit. Office Manger Angelica Arambulo was unable to be at the facility during today’s visit and authorized Catalina Gonzales to sign and receive the report. The purpose of today's visit is to address a self reported Unusual Incident/Injury Report (LIC 624) reported to CCL on 09/19/2023. The self reported Unusual Incident/Injury Report (LIC 624) pertains to an incident that occurred on 9/06/2023 regarding Residents #1 (R1), two staff (S1, S2), and a visitor. It was documented that on the evening of 9/6/2023 R1 did not want to be changed and S1 asked a visitor to hold R1, then S1 and S2 continued to to change R1 in front of the visitor, violating R1's personal rights. It was further reported that R1 had been combative due to not being provided their 1 p.m. and 5 p.m. medications by S1. S1 was terminated on 9/06/2023. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to 809-D). Exit interview conducted. Copy of report and appeal rights issued at the time of the visit.