Incident investigation·December 2, 2025

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to Unusual Incident Reports (UIRs). SOC341 and Death Report submitted by the facility. LPA met with Associate Executive Director (AED) Rosana Frias and informed the reason for visit. UIRs indicated the following: 1. Resident (R1) UIR indicated that on 11/12/25, the facility received a call from a community that R1 was at the community's lobby. The Resident Care Coordinator and Memory Care Director went to the community and brought R1 back to facility. Family member was informed. 2. Death Report (DR) for resident (R2) DR indicated R2 passed on 11/09/25. R2 was in hospital ICU at the time of death. R2 was sent out to the emergency on 9/29/25 when R2 cried of head pain after an unwitnessed fall. 3. Resident (R3) On 11/24/24, R3 reported missing $800 in cash in her apartment. Executive Director met with R3, checked R3's apartment and didn't find any cash in the apartments and bags R3 said R3 keeps. There was no witness to the said incident. The facility also submitted a copy of SOC341. continued on 809C On this same day, 12/02/25, LPA reviewed residents' files and obtained copies of including but not limited to the following documents: LIC601 Identification and Emergency Contact Information; LIC602A Physician's Reports; Care Plan; LIC621 Client/Resident Personal Property Valuables. LPA checked the front door and conducted interviews. LPA observed the following: -at 12:00 pm, R1's LIC602A Physician's Report showed R1 has major neurocognitive disorder and cannot leave the facility unassisted. R1's assessment dated 11/17/25 not consistent with current care need. Assessment indicated resident wanders only within the common areas of the secured community . -at 12:20 pm, the front entrance/exit door does not have auditory signal. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalty. Deficiencies and plan and proof of corrections were discussed with AED. Exit interview conducted. Appeal Rights,LIC9098 Proof of Correction form and copy of this report provided.