Facility Evaluation Report

On 5/20/2025 at approximately 10:30 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced subsequent Case Management visit to the facility. LPA was greeted by staff and stated the reason for their visit was to deliver the findings regarding the incident reported to Community Care Licensing Division (CCLD) on 5/2/2025. Executive Director (ED) Katherine Aleman arrived shortly after to assist with today’s visit.

Upon arrival, LPA requested Census, Staff and Resident Roster. At approximately 10:40 AM LPA requested additional documentation pertaining to the incident. Between 11:00 AM – 12:00 PM, LPA conducted additional interviews with Staff members (S5-S6).

To investigate the incident, on 5/5/2025 LPA conducted a physical plant tour, requested pertinent documentation, and conducted interviews with one (1) Resident (R1) and four (4) Staff members (S1-S4).

The facility reported that R1 had reported that S1 used inappropriate physical force towards them causing them pain. LPA spoke with the ED regarding the incident between R1 and S1. The ED stated that when they became aware of the alleged incident, they proceeded to conduct their own internal investigation as well as reporting the incident to the appropriate domains. The ED stated they interviewed both R1 and S1 but since there were no witnesses their investigation was inconclusive. LPA’s interview with R1 revealed that S1 had arrived in their room in the morning to assist them in bed with their incontinent care needs. R1 stated that S1 pushed their head down twice by placing their finger onto their forehead to get their head onto the bed. When LPA asked if they could name the staff member, R1 could not remember and stated, “I am not good with names”.When LPA asked if they had told anyone what had occurred, R1 stated they told S3 what had occurred. LPA’s interview with S3 revealed that R1 had told them that a staff member had “manhandled” them when assisting them in the morning. When LPA asked if R1 had told them the name of the staff member, S3 stated that R1 did not know the name of the staff member. (Continue to LIC 809-C)