Incident investigation·November 14, 2025

Licensing Program Analyst (LPA) David Roman conducted an unannounced Case Management Inspection. LPA D. Roman identified himself to Gabriela Zamora, and discussed the purpose of the visit. LPA D. Roman reviewed the resident records, intake assessment. The residents records illustrated admissions to the facility on 10/07/2025, with no SI, no SH BX's. Resident received EMS due to his on going behaviors of self harm. Staff reported the resident was to be sent to a crisis center in San Diego. LPA D. Roman along with facility staff toured the interior and exterior of the facility and inspected bedrooms and bathrooms. LPA D. Roman observed the residents bedroom where the incident occurred. The facility was sanitary, and in good repair. Pathways were free of obstruction and slip hazards. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents, medication cart is locked. No pools or bodies of water on the premises. An exit interview was conducted with Facility Manager, Gabriela Zamora.