Facility Evaluation Report

LPA Joseph Alejandre made an unannounced visit to deliver the findings of the investigation into the incident involving Resident 1 (R1) that took place at the facility on December 20, 2024. LPA met with Administrator (AD) Ashiman Gill and explained the reason for the visit. During the course of the investigation, Department staff inspected the facility, interviewed AD, witnesses, and staff, and obtained and reviewed records, staff roster, staff schedule, R1’s emergency contact information, R1’s physician’s report dated November 1, 2023, R1’s resident appraisal dated September 13, 2021, R1’s Physician order review (prescription list), facility surveillance camera footage from December 20, 2024, photographic evidence of R1 from December 21, 2024, Kaiser Permanente medical records dated December 20 to 24, 2024, R1’s after visit summary records dated December 26 and December 31, 2024.

The investigation revealed following, The Director of Resident Engagement (DRE) Alyssa Herris led an engagement activity for residents on December 20, 2024, around 3:00 pm. The activity consisted of making a dried resin floral coaster. R1 was one of five participants. Two staff members were present during the activity. There were two bottles of Epoxy Resin (glue) that were mixed and poured in a red solo cup for residents to use in making the coaster. The DRE reported that putting resin in a cup was typical whenever they had a similar activity. The DRE admitted to placing the cup of resin on the table next to R1 and turned away from R1 to redirect another resident. R1 picked up the cup and started to take a few sips. The DRE turned and was facing R1 but was talking to another resident. The DRE saw R1 holding the cup by their mouth, so they went to R1 and took the cup away from R1. This information was verified by surveillance camera footage. R1 then stated, “I don’t want any more of that.” The DRE immediately notified the facility’s Director of Health Services (DHS) Elizabeth Retts. The DRE and DHS gave R1 some water and contacted the Nurse (N1) to assess R1 at 3:27pm. N1 reported that R1’s vital signs were normal.