Facility Evaluation Report

03/12/2026 01:30 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Grace Hawkins. Today’s visit is regarding an incident that occurred on 02/16/2026. This is a follow-up visit to deliver findings.

It was reported that on 02/16/2026 staff witnessed Staff 1 (S1) retrieve a bottle of Febreze from the upper service area, bend down, and spray the product directly onto Resident 1’s (R1) genital area. Two other staff members were present during the incident. All three staff were suspended as a result. R1’s physician, family, and local law enforcement were notified of the incident.

Interviews revealed that staff witnessed Staff 1 spray Febreze on Resident 1. Staff 1 has been fired as a result of this incident.

It was determined that Staff 1 (S1) handled R1 in a rough manner when they sprayed the resident with Febreze which violates R1’s personal rights.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. Appeal rights were provided. Exit interview was conducted and the report was provided to Executive Director Grace Hawkins.