Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced Case Management visit to investigate the incident that occurred on 10/12/25 and reported to the Department on 10/17/25, regarding Resident #1. LPA Yee met with Aaron Mays, Designated Executive Director. The reason for today's visit was explained.

Per information provided on the LIC624, Special Incident Report, Staff #2 observed Staff #1 push Resident #1. No other details were provided regarding the incident on the report. Upon further inquiry into the incident, the following was revealed. On 10/12/25, around 4am, Staff #1, who works the night shift was doing laundry and had left the laundry cart with Resident #2's clothes by their door and had stepped away. Resident #1, who has dementia was wandering around, grabbed a pair of Resident #2's pants from the cart. Staff #1 noticed and attempted to get the pants away from Resident #1. Resident #1 got mad and threw the pants on the floor and began stepping on it. Staff #1 and Staff #2 attempted to get the resident off the pants. Staff #1 got irritated and pushed the resident, causing the resident to fall on the floor and landing on their back. Staff #1 and Staff #2, both assisted Resident #1 to get up. Resident #1 walked with a limp. Per Staff #2, when they were changing Resident #1, a big bruise was observed on the resident's arm and bottom. This incident was reported to Staff #3 when Staff #2 returned to work later that evening. Staff #4 was not advised of the 10/12/25 incident until 10/14/25. Staff #1 who was off on 10/13/25, was suspended via telephone on 10/14/25 by Staff #4 and the designated Executive Director was also notified that morning.

An internal investigation was attempted and Staff #1 was given the opportunity to come into the office