Facility Evaluation Report

L icensing Program Analyst (LPA) Tao conducted an unannounced Case Management- Incident visit in response to resident#1 (R1)’s incident, dated 01/12/24, reported on SOC 341 by Jennifer Zhang, Administrator. The facility is licensed to serve residents of age 60 years old and above, approved for 99 non- ambulatory. Approved hospice care waiver for 15 residents. LPA explained the purpose of today's visit to Jennifer, Administrator, who assisted with this visit.

LPA obtained copies of staff/residents rosters, R1’s Identification/Emergency Contact Information, R1'a Needs and Service Plans, Unusual Incident Report 01/12/24 and Progress notes.

During today's visit LPA toured the facility, interviewed Administrator, resident#1 (R1), staff#1 (S1) and reviewed R1's file. LPA attempted to interview staff#2 (S2) but S2 declined to be interviewed. The incident report stated S2 physically assaulted R1 when changing R1’s diaper. R1 refused to have R1’s diaper changed, became agitated and grabbed S2’s collar. S2 attempted to release S2 from the situation and pushed R1 away which R1 rolled to the right in bed and hit the wall Resident was found to have wounds on resident's upper extremities and lower face. Police came and took S2 to the police office for investigation.

Per staff and resident interviews, the incident happened on 1/12/24. Staff was assisting resident. Due to language barrier, the resident was mis-communicated with the staff and got agitated. It was a single incident happened at the facility.