Incident investigation·May 14, 2026

On 5/14/2026 at 3:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct Case Management Inspection in regards to incident report. LPA met with Business Services Manager, Preet Ghuman and explained the reason for the visit. Based on the incident report received, resident (R1) was found by local law enforcement and transported to the hospital due to unwitnessed fall. R1 fell after leaving the facility. During visit, LPA reviewed R1's file including physician's report, care notes, care plan, and incident report. R1's physician's report indicated that R1 cannot leave the facility unassisted. Interview with staff revealed that R1 left the facility from the side door and R1 did not have a wander guard on when leaving the facility. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.