Incident investigation·November 4, 2025

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management - incident visit at 12:50PM. Upon arrival, LPA met with staff and Executive Director (ED) Brian Larios. Entrance interview conducted. During today’s visit, LPA conducted a brief physical plant tour, conducted interviews with ED and Health and Services Director Ian Gadea, and reviewed and obtained copies of pertinent documents relevant to the investigation. On 10/27/2025, the Department received an incident report stating that on 10/20/2025 around 01:30PM, a staff member heard Resident #1 (R1) call for help from their apartment and staff observed R1 laying on the floor. R1 was transported to the hospital, and it was determined that R1 had fractured both femurs and their left arm. During today’s visit, LPA conducted a file review and observed that R1’s physician’s report signed and dated 08/18/2025 documents R1 with osteopenia and osteoarthritis, affecting bone mass and density. R1’s care plan signed and dated 09/03/2025 documents that R1 “requires one-person physical assistance with transfers.” However, R1 attempted to self-transfer and tripped on their wheelchair. LPA reviewed pendant response times and observed that on 10/20/2025, R1 pressed their pendant at 01:31PM and it was cleared by staff at 01:34PM. 9-1-1 was called by staff at 01:34PM. LPA observed R1's room and did not observe any tripping hazards or immediate health and safety concerns. Report Continued on LIC809-C. Furthermore, on 10/27/2025, the Department also received multiple incident reports for incidents that occurred on the following dates: 09/25/2025, 09/27/2025, 09/29/2025, 10/01/2025, and 10/11/2025. Regulation states that incident reports shall be submitted within seven (7) days of occurrence. LPA discussed reporting requirements with the ED. ED stated that a plan has been put in place to ensure that the timeline for incident reporting will be in compliance. Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited for reporting requirements (refer to LIC 809-D). Administrator was informed that failure to correct deficiency may result in civil penalties. An additional report may follow if warranted. Exit interview conducted, report issued, and appeal rights provided.