Facility Evaluation Report

On 11/10/2025 at 9:15am, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannounced Case Management- Incident visit to the facility listed above. LPA met with Marielena Cardenas, Business Office Director, and the purpose of today’s visit was explained. LPA was granted entry into the facility.

On 11/05/2025, the Regional Office received an Unusual Incident/Injury Report stating that on 11/04/2025 Staff (S1) was observed by facility Staff (S2) shoving Resident (R1) into their wheelchair by pushing their left shoulder downward. Once Resident R1 was in their wheelchair, S1 proceeded to remove their soiled gloves and throw the soiled gloves and soiled wipes at Resident R1.

During today’s visit, LPA received a Resident Roster, Staff Roster, Incident Report, SOC341, Resident Notes, In-Service Logs, interviewed Staff S2-S7, interviewed Witnesses W1-W2, and interviewed Resident R1.

During interviews with Staff S2-S7 were asked if they observed S1 being physically aggressive with residents, five (5) out of six (6) stated no, they have not observed S1 be physically aggressive with residents. During an interview with Resident R1 was asked if they feel safe here at the facility, R1 stated yes.

During Record Review, LPA observed Staff S1 was sent home and removed from the schedule following the incident. Additionally, Culver City Police Department were called out to investigate and provided case # 25-5668. LPA received and reviewed In-Service training logs (dated 11/08/2025) regarding Mandated Reporters, and Safety while providing ADLs.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies during this visit; therefore, no citations were issued.

An exit interview was conducted with Marielena Cardenas, Business Office Director, and a copy of this report was conducted.