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13 | *This is an amended report to the original 9099 delivered on 11/5/2021.
On 11/5/2021 Licensing Program Analyst (LPA), L. Ibo arrived unannounced to deliver findings for the above allegations. LPA met with Michela Cianciosi and explained that the reason for the visit. This complaint is from December 2020 and primary investigation was completed by another LPA Praveen Singh, complaint was re-assigned to LPA L. Ibo.
During the course of investigation based on interview, recorded video and records review, S2 physically abused R1. Video footage timestamped 11/18/2020 showed R1 was at the dining room in memory care unit with other residents when S2 moved one dining chair away from R1, S2 moved in circles, pushed R1’s forehead, pulled R1’s hand, grabbed resident’s head, wiggle it around until R1 fell on the floor. On 11/20/2020 care staff observed R1 with bruising on elbow and bump on the back of her head. Based on documentation reviewed R1 is a fall risk. R1 was sent to the hospital on 11/20/2020 for unwitnessed fall and was sent back to the facility on the same day with no hospitalization needed. However, it is uncertain if bruises and bump observed are from the incident from S2 pushing R1 as the video footage abruptly cuts off. Staff interviewed R1 and resident cannot recall any fall incident.
...Continued on LIC9099C...
During the course of the investigation based on video recording and records review, S3 was the one filming the physical abuse incident between S2 and R1, based on the audio from the video , you can hear S3 laughing at the incident, this took place at the common area at the dining room, these actions violated personal rights of R1.
During the course on investigation based on records review and video recording, there are two videos were S3 & S4 witnessed S2 physically abusing R1 but failed to comply as mandated reporters.
This complaint was investigated by the Department and based upon records review and interviews has determined the preponderance of evidence has been met, and that the allegations valid and SUBSTANTIATED.
A formal meeting will be scheduled at a later time.
The licensee has been informed that an additional civil penalty may be assessed based on Health and Safety Code 1569.49 for death, physical abuse, or serious bodily injury in RCFE.
Deficiency is cited from the California Code of Regulations, Title 22, on the LIC 9099-D form. Failure to submit proof of correction (POC) by POC date any repeat violations within a 12-month period may result in additional civil penalties.
Deficiency and plan and proof of correction were discussed with Michela Cianciosi and Katelyn Wilson.
Exit interview conducted. Appeal Rights and copy of this report provided.
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| Substantiated | Estimated Days of Completion: |
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Under Appeal
Type A
11/10/2021
Section Cited
HSC
1569.269(a)(10) | 1
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7 | 1569.269 (a) Residents of residential care facilities for the elderly shall have all of the following rights....(10)To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.
This requirement was not met as evidenced by: | 1
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7 | Administrator agreed to conduct training of all staff with an emphasis on how to identify elder abuse. Facility will conduct training focusing on the health and safety 1569.269(a)(10) |
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14 | Based on video evidence licensee did not comply with the section as cited above S2 physically abused R1, by pushing resident and resident fell on the floor, R1 sustained bruises and bump on the head which poses an immediate health and safety risk to residents in care. | 8
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14 | A copy of topics discussed with staff signatures of those in attendance will be sent to CCL by POC date.
Facility already terminated S2, S3 & S4.
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Under Appeal
Type A
11/10/2021
Section Cited
HSC
1569.269(a)(1) | 1
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7 | (a) Residents of residential care facilities for the elderly shall have all of the following rights:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement was not met as evidenced by: | 1
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7 | Administrator agreed to conduct training of all staff with emphasis on personal rights of residents in care, training should be focusing on health and safety 1569/269(a)(1). |
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14 | Based on video and document review, S3 was the one filming the physical abuse incident between S2 and R1, based on the audio from the video , you can hear S3 laughing at the incident, this took place at the common area at the dining room which posed an immediate safety & health risk to residents in care. | 8
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14 | A copy of topics discussed with staff signature of those in attendance will be sent to CCL by POC date.
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
11/10/2021
Section Cited
CCR
87211(c) | 1
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7 | (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman.... and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1).
This requirement is not met as evidence by:
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7 | Administrator agreed to conduct training of all staff with an emphasis on mandated reporting and self-certification that staff will comply with Title 22 Section 87211 reporting requirements regulations. |
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14 | Based on interview and records review S3 & S4 witnessed S2 physically abusing R1 but did not report, which poses an immediate health and safety risk to residents in care. | 8
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14 | A copy of topics discussed with staff signatures of those in attendance will be sent to CCL by POC date.
Facility already terminated S2, S3 & S4 |
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