Facility Evaluation Report

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20250507114305. LPA met with Chief Operating Officer (COO) Faye Shen and explained the reason for today’s inspection.

During the course of the investigation, LPA inspected the facility, interviewed staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #2’s (R2) Physician’s Report dated January 1, 2025, and R2’s Appraisal/Needs and Services Plan dated February 1, 2024.

LPA interviewed the facility’s medication technician supervisor who stated that on May 3, 2025, staff in the third-floor memory care heard a fall, observed Resident #1’s (R1) door open with R1 on the floor inside and R2 standing outside the room, noted no serious injuries on R1, offered R1 first aid and reported the fall to R1’s doctor, but did not observe whether R1 fell or was pushed by R2. LPA interviewed three staff who were witnesses to the incident, and one confirmed seeing R2 push R1 causing R1’s fall. All four staff interviewed also confirmed that R2 has a history of aggression. LPA reviewed R2’s Physician’s Report dated January 1, 2025, which indicates R2 has Dementia, and R2’s Appraisal/Needs and Services Plan dated February 1, 2024, which was not updated as required due to R2’s Dementia diagnosis.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.