Incident investigation·January 7, 2026

On 01/07/2026 at 1:20 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident that was sent on 12/17/2025. LPA met with Director of Operations, Angel Lee, and explained the purpose of the visit. The Executive Director was not available during today's visit. Incident report indicated that Resident 1 (R1) had an unwitnessed fall on 12/16/2025. R1 was experiencing mild pain and was resolved with pain medications. On 12/17/2025, R1 had a change in condition and was sent to the Emergency Room (ER). During the visit, LPA reviewed After Visit Summary, Physician Fax Report Form, Unusual Occurrence Report (Facility Incident Report), Service Plans dated 11/26/2025 and 12/18/2025, and R1's physician report. LPA interviewed 3 staff members. LPA interviewed Staff 1 (S1) and Staff 2 (S2) revealed that R1 is a high risk for falls. A review of R1's service plan indicated that R1 was placed on the additional safety checks throughout the day effective 12/16/2025 and on the Augi sensor system on 11/26/2025. Interview with S2 revealed that communication between family regarding 1:1 care was conducted through the phone after the fall incidents had occured. S3 stated that they heard the motion alarm sound on 12/16/2025, and when they checked on R1, they found R1 on the floor. LPA will be requesting additional communication log between the facility and family regarding 1:1 care services. No deficiencies cited. Exit interview conducted and a copy of this report was provided.