Facility Evaluation Report
On 8/5/2026, LPA Grace Donato conducted an unannounced Case Management - Incident visit. LPA met with Director of Nursing (DON), Carol Blackwell and explained the purpose of the visit.
On 7/30/26 at around 10:30am, facility became aware of an alleged resident (R1) abuse in cide n t inv olving a Hospice Aid while providing personal care to the resident who became resistive prior to receiving shower. Witnesses reported that the aid handled the resident roughly, placed hand to the R1s mouth & continued the shower despite t he nurse ' s instruction to stop the care & allow time for the R1s medications to take effect.
Facility staff immediately reported what they had witnessed to LVN on shift.
LPA spoke with DON, Facility has a practice of having a facility staff help with any hospice resident when hospice staff are around. DON did all the cross reports necessary. R1 did not sustain any injury during the shower. Hospice facility has provided a new hospice aid for R1.
LPA collected documents from the facility.
No citations issued today. Report is reviewed and copy is provided.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction