Facility Evaluation Report

Licensing Program Analysts (LPAs) Dang Nguyen and Juliana Barfield conducted an unannounced Case Management - Incident visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Suzette Johnson.

Today's visit was in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office (received on 12/27/2023), involving Staff #1 (S1) and Resident #1 (R1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, LPAs performed a facility tour. At the time of the visit, R1 was off-site and unable to be interviewed. However, a welfare check was performed on other residents in care. LPAs also reviewed pertinent care and investigative records and interviewed other relevant residents and staff.

According to R1’s latest LIC602 Physician’s Report (dated 10/23/2023), R1 was diagnosed with Dementia. Their doctor stated that while R1 was “confused/disoriented,” R1 was also able to follow instructions and able to communicate needs.

According to staff interviews: Multiple managers and caregivers noted that R1 had a tendency towards tactile stimulation, sometimes touching things or others out of curiosity. During the evening of 12/23/2023, R1 touched Resident #2’s (R2) shoulder, which bothered R2. Staff #2 (S2) said they saw S1 slap R1’s arm. S2 reported their concerns about the incident to facility management. In their written statement, S1 said they “grab[bed]” R1’s hand to redirect them away from R2. There were no injuries to either resident.