Incident investigation·December 18, 2025

On 12/18/2025 at 2:00 p.m., Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a case management visit regarding an incident report received by the Community Care Licensing Division (CCLD) on 12/16/2025. LPA met with Interim Executive Director (ED) Ricardo Romero, Sr., and explained the purpose of the visit. The Unusual Incident Report (UIR) indicated that on 12/13/2025 at approximately 10:41 p.m., Resident (R1) was found on the floor by Staff (S1). S1 contacted 911 and conducted an initial assessment, during which bruising was observed on R1’s forehead. R1 was transported to the hospital emergency room for further evaluation. The UIR reported that R1 returned to the facility with no ongoing concerns. During the visit, LPA interviewed S2, who stated that R1 frequently walks back and forth within the memory care unit and has demonstrated increased wandering behaviors. S2 stated that the facility has requested an updated physician’s report (LIC602-A) from R1’s primary care physician. S2 further stated that following R1’s return to the facility, the licensee implemented alert charting every shift and is currently completing a new assessment and updating the care plan for R1. LPA collected and reviewed the following documents: R1’s physician’s report (LIC602-A), care plan (dated 01/02/2025), Fax confirmation requesting an updated LIC 602A (dated 10/15/2025) and Care Tracking Log (dated 12/14/2025 through 12/18/2025). No deficiencies were issued during visit. An exit interview was conducted, and a copy of this report was provided.