NARRATIVE |
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25 | Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite a deficiency identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Monica McDade.
CCLD’s complaint investigation revealed that on a date in mid-November 2024, Licensee’s staff, Staff #1 (S1), abused Client #1 (C1) by forcefully smothering their face with a pillow while C1 yelled/screamed. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] The evidence did not show that this incident of abuse resulted in serious bodily injury.
Interviews showed that multiple facility staff were aware of the above incident, in which C1 was a victim. However, prior to CCLD’s complaint investigation, Licensee and their staff did not notify the following parties of the incident: C1’s conservator / responsible person, C1’s San Diego Regional Center (SDRC) Coordinator, CCLD, the Long-Term Care Ombudsman Program (LTCOP), or local law enforcement. (Subsequent to CCLD's investigation, each of the above parties were notified.)
Per regulation, Licensee was required to report “any suspected physical abuse that does not result in serious bodily injury” to CCLD, LTCOP, and local law enforcement within twenty-four (24) hours. Licensee was additionally required to send a written report of “any psychological abuse of any client” to CCLD within seven (7) days.
Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). Plans of Correction was jointly developed with the Licensee.
An exit interview was conducted with McDade, to whom a copy of this report, the LIC 809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
|
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
01/03/2025
Section Cited
CCR
80061(b)(1)(F)
| 1
2
3
4
5
6
7 | 80061 Reporting Requirements: “(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report… shall be submitted to the licensing agency within seven days…(1) Events reported shall include the following: (F) Any suspected psychological abuse of any client.” | 1
2
3
4
5
6
7 | Licensee agreed to retrain all managers and current staff on California Mandated Reporting Requirements. The training will involve, at minimum, use of an approved video on the topic from the California Department of Justice, hands-on practice with completing an SOC341 form, and review of the text of CCR 80061 Reporting Requirements. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date. |
 | 8
9
10
11
12
13
14 | This requirement was not met, as evidenced by: Based on records, interviews, and video, 1 of 3 clients (C1) was the victim of suspected psychological abuse, and Licensee did not submit a written report to the licensing agency within seven days. This posed a potential personal rights risk to persons in care. | 8
9
10
11
12
13
14 | |
Type B
01/03/2025
Section Cited
CCR80061(d)
| 1
2
3
4
5
6
7 | 80061 Reporting Requirements: “(d) 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, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1).” | 1
2
3
4
5
6
7 | Licensee agreed to retrain all managers and current staff on California Mandated Reporting Requirements. The training will involve, at minimum, use of an approved video on the topic from the California Department of Justice, hands-on practice with completing an SOC341 form, and review of the text of CCR 80061 Reporting Requirements. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date. |
| 8
9
10
11
12
13
14 | This requirement was not met, as evidenced by: Based on records, interviews, and video, 1 of 3 clients (C1) was the victim of physical abuse that did not result in serious bodily injury, and Licensee did not report it to the local ombudsman, the corresponding licensing agency, and local law enforcement within twenty-four (24) hours. This posed a potential health, safety, and personal rights risk to persons in care. | 8
9
10
11
12
13
14 | |