Facility Evaluation Report

Licensing Program Analyst (LPA) Loera conducted an unannounced case management inspection and met with Yvette Morgan, Program Operations Manager and Krysteena Brice, Manager. The purpose of this case management inspection was to follow up on self reported incident submitted to Community Care Licensing (CCL) on 03/12/2025.

Incident Report states on 3/11/2025, staff (S1) was observed swinging facility keys by the string and making contact with resident's (R1) elbow while yelling "hello" in a loud demanding voice when R1 was not engaging with S1. R1 was sitting quietly in their chair with S1 besides R1 on the couch. S1 was asking R1 questions like, "why do you have so many newspapers?" and repeating "hi" to R1. R1 appeared startled by the keys but did not sustain physical injury.

S1 was suspended and pending termination based on prior disciplinary investigation findings conducted by facility. Facility reviewed and updated their policies and enhanced supervision protocols were implemented.

Community Care Licensing (CCL) confirmed facility reported appropriately to CCL, Ombudsman, Golden Gate Regional Center (GGRC).

Per conversation with manager all staff are to receive refresher training on client rights, dignity, and professional communication.

Per conversation, LPA suggested facility staff to receive training by an outside vendor such as GGRC.

See LIC809-D for Deficiency. Exit interview conducted with Program Manager and a copy of this report along with LIC811 (Confidential Names) was provided .