Incident investigation·May 6, 2025

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management Incident inspection at the facility today. The LPA met with Administrator Joeyvic Alvarado and explained the reason for the inspection. On 02/27/2025, Community Care Licensing (CCL) received an Unusual Incident/Injury Report (LIC 624) pertaining to Resident #1 (R1). The report stated that on 02/25/2025, while walking on the beach with several residents, R1 lost their balance and fell. R1 was transferred to the hospital for immediate medical treatment. Furthermore, R1 returned to the community on 02/26/2025 with a back fracture. On 02/28/2025, the LPA spoke with Administrator Joey Alvarado regarding the incident via a telephonic interview. On 03/12/25, the LPA conducted a case management visit regarding the incident and issued a deficiency. During today's visit the LPA conducted an interview with the Administrator, four (4) staff, a file review and collected pertinent documents related to the incident. No citations are being issued at this time. The LPA may return for a follow up for further investigation if needed. A $500 immediate civil penalty was assessed on 03/12/25. The Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and/or 1569.49(f). Exit interview conducted. A copy of the report was issued.