Incident investigation·January 18, 2024

Licensing Program Analysts (LPA’s) Martha Arroyo and Brian Balisi conducted an unannounced case management visit to the above facility. The purpose of this visit is to conclude an investigation regarding an incident that occurred on 01/01/2024. Upon arrival, the LPAs met with Executive Director (ED), Margie Veis, and explained the reason for the visit. Entrance interview. On 01/02/2024, the Department received an incident report stating that on the morning of 01/01/2024, Staff #1 (S1) was assisting Resident #1 (R1) with dressing. R1 was resistant to care and became agitated. R1 slapped S1 across the face, causing S1’s glasses to fall off their face and in response, S1 slapped R1 across the face. Staff #2 (S2) witnessed the incident as they were inside the room assisting S1. During the initial visit on 01/05/2024, LPA Arroyo conducted a tour of the Memory Care Unit at 12:20 p.m., conducted interviews with the ED and two staff between 12:13 p.m. and 12:45 p.m., conducted a file review at 1:05 p.m., and obtained copies of pertinent documents relevant to the investigation. Information obtained during the course of the investigation revealed that R1 was agitated while being provided care by both S1 and S2. This resulted in R1 slapping S1 causing their glasses to fall from S1’s face. In response, S1 slapped R1 across the face. Interviews conducted revealed that S2 had seemed short tempered with the residents lately and S2 had reported to other staff that it was only a reaction that happened without thinking due to being slapped. (Report Continued on LIC 809C...) (Report Continued from LIC 809C...) However, staff stated observing S2 being slapped by other residents in the past but denied seeing any reaction from S2. In addition, both law enforcement and R1’s family were contacted and notified of the incident on the same day it occurred. Hospice was also notified shortly after the incident to come to the facility and educate the staff on how to deal with residents’ behaviors. Furthermore, S1 resigned from their position on their own following the incident. Based on the information obtained and reviewed, the Department has enough evidence to say that S1 slapped R1 while providing care. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit. Exit Interview conducted. Copy of report, and appeal rights provided.