Facility Evaluation Report

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Case Management - Incident visit. LPA was welcomed by Susan O'Shaughnessy, the Director of Marketing and Admissions, and discussed the purpose of the visit.

Today's visit was in response to an Incident Report (LIC624) that the licensee self submitted to the CCLD San Diego Regional Office. According to the LIC624, on 8/21/24, Resident #1 (R1) was involved in an incident where a Staff 1 (S1) had a physical altercation with R1.

The video shows R1 and S1 hitting and pushing each other. R1 falls to the ground and crawls on the floor until they can get up, while S1 watched and does not assist R1. R1 is seen on the video wiping blood from their hand. R1 tries to stop the bleeding with a tissue, while they bend over to wipe the blood from the floor. Staff 2 (S2) came to the memory care unit, where they saw the cut on R1's hand and applied aid.

R1 was taken to the emergency room, where the resident received four stitches.The facility did not notify R1's responsible party of the incident.

During today’s visit, LPA performed a facility tour, welfare check, collected records, observed R1, and interviewed staff.