Incident investigation·January 26, 2026

Licensing Program Analysts (LPA)s Brian Balisi and Martha Arroyo conducted an unannounced case management  visit to follow up on a recent incident report. Upon arrival, LPA  met with Executive Director Angela Avakian and explained the reason for the visit. On 01/10/2026 - at approx 11:00 P.M, during NOC shifts, Resident #1 (R1) reported to med tech that the last care provider (Staff #1(S1)) was throwing R1 around, hit R1 back on the railings of the bed, and threw their glasses on their dresser. Med Tech notified Memory care Director and stated R1 did not report being in pain, however was crying. MCD assessed resident for any injuries. R1 was observed with no visible redness, bruising, or markings. R1 did not complain of any pain or discomfort. MCD observed resident glasses not broken, showing no signs of damage, placed on top of R1's night stand. At approx 10:00 a.m. LPA's conducted physical plant, interviewed  staff, resident and reviewed and obtained copies of pertinent documentation relevant to the investigation. No immediate health and safety concerns were observed during the visit. No citations issued during the visit. LPA's have determined further investigation is needed and will return at a later date to complete the investigation if warranted. Exit interview conducted, and copy of report issued.