Facility Evaluation Report
On December 29, 2023, Licensing Program Analyst (LPA) Komal Charitra met with Activities Director, Kathleen Sullivan for a Case Management visit to follow up on a substantiated allegation from an incident that occurred on May 28, 2023, regarding two residents; Resident 1 (R1) and Resident 2 (R2) who were physically abused by a staff member (S1).
On September 22, 2023, the Department concluded an investigation which alleged that S1 physically abused R1 and R2 on May 28, 2023. The allegation of physical abuse was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § “87468.1(a)(2)” Personal Rights of Residents in All Facilities.
The investigation revealed that S1 is a clerical/administrative staff member with no formal training in caregiving duties. S1 also failed to complete the criminal record exemption process after an arrest and was disassociated from the facility in 2021 but continued to work in the facility until their resignation on June 1, 2023.
On May 27, 2023, the night shift had a last-minute call-off and S1 overheard the staffing concern and offered to volunteer to stay for overtime. Staff 2 (S2) and Staff 3 (S3) approved S1’s request for overtime as a last-minute caregiver to cover for the call-off for the night shift. According to the administrator, there are usually four staff members for the night shift, but on the evening of May 27, 2023, to the morning of May 28, 2023, there were only three staff members: S1, Staff 4 (S4) and Staff 5 (S5). During this shift, S4 only saw S1 when they arrived to work and denied having any further interaction with S1 the rest of the shift. During S5’s shift, S5 recalled that S1 and S5 went to three residents to offer incontinence care (diaper changes) at around 1:35 a.m., R1 was one of the residents but declined care. S5 denied seeing S1 after 3:00 a.m. R1 has a camera inside their room and camera footage captured S1 (identified by the administrator) entering R1’s room alone at 3:18 a.m. (Cont. to 809C).
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction