Facility Evaluation Report

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite a deficiency identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Monica McDade.

CCLD’s complaint investigation revealed that on a date in mid-November 2024, Licensee’s staff, Staff #1 (S1), abused Client #1 (C1) by forcefully smothering their face with a pillow while C1 yelled/screamed. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] The evidence did not show that this incident of abuse resulted in serious bodily injury.

Interviews showed that multiple facility staff were aware of the above incident, in which C1 was a victim. However, prior to CCLD’s complaint investigation, Licensee and their staff did not notify the following parties of the incident: C1’s conservator / responsible person, C1’s San Diego Regional Center (SDRC) Coordinator, CCLD, the Long-Term Care Ombudsman Program (LTCOP), or local law enforcement. (Subsequent to CCLD's investigation, each of the above parties were notified.)

Per regulation, Licensee was required to report “any suspected physical abuse that does not result in serious bodily injury” to CCLD, LTCOP, and local law enforcement within twenty-four (24) hours. Licensee was additionally required to send a written report of “any psychological abuse of any client” to CCLD within seven (7) days.

Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). Plans of Correction was jointly developed with the Licensee.

An exit interview was conducted with McDade, to whom a copy of this report, the LIC 809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.