Follow-up·April 23, 2026

At approximately 8:55AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other visit and met with Executive Director, Kimberly Humphrey. The purpose of today's visit was to conduct the facility's quarterly Non-Compliance inspection and to follow up on self reported incident reports that were submitted to the Santa Rosa Regional Office (SRRO). LPA reviewed files for staff members hired from February 2026 to April 2026 related to the below concerns: Reporting Requirements Personal Rights Incidental, Medical, and Dental Care Welfare and Institutions Code Administrator and Designated Representatives LPA observed that identified staff members hired within this time frame had appropriate training documented or their training was scheduled to be completed. LPA requested for copies of scheduled training to be submitted to the Department once complete. Community Care Licensing (CCL) received the following incident reports: Incident Report 1 was submitted to CCL on 02/04/2026. Report states that on 01/31/2026, Resident 1 (R1) was observed sitting in a car in the facility's parking lot. The car belonged to another resident's family member. R1 was redirected back to the facility. Facility made all appropriate notifications per regulation. Review of R1's care plan dated 12/31/2025 stated that R1 did not have a history of elopement. Per Executive Director, this Continued on LIC809C Continued from LIC809 incident prompted facility to have R1 reassessed for this change of behavior. Review of R1's updated Physician Report dated 02/16/2026 and updated Care Plan dated 02/12/2026 showed they are unable to leave unassisted. Incident Report 2 was submitted to CCL on 03/26/2026. Report states that on 03/25/2026, R1 was observed pulling the hair of Resident 2 (R2). Facility staff intervened, separated the residents, and assessed for injury. Facility made all appropriate notifications per regulation. Incident Report 3 was submitted to CCL on 03/26/2026. Report states that on 03/25/2026, R1 was observed to hit Resident 3 (R3) twice on the cheek with a closed hand. Facility staff intervened, separated the residents and assessed for injury. Facility staff provided first aid. Facility made all appropriate notifications per regulation. Incident Report 4 was submitted to CCL on 04/02/2026. Report states that on 04/02/2026, R4 fell and hit their head on the floor in their room. Per report, the incident occurred due to Staff Member 1 (S1) not ensuring that R4 was sitting properly in their wheelchair before being transferred, causing R4 to fall forward onto the floor. Paramedics were contacted to further evaluate R4 and responsible party refused transport to the Emergency Room. R4 was placed on 72 hour observation. Facility made all appropriate notifications per regulation. Incident Report 5 was submitted to CCL on 04/20/2026. Report states that on 04/15/2026, Resident 5 (R5) was observed to grab Resident 6 (R6) by the back of their head and hit the top of their head with an open palm. Facility staff intervened, separated the residents, and assessed for injury. Facility made all appropriate notifications per regulation. LPA obtained copies of documents related to the incidents. Elopement training was conducted on 02/04/2026 and 02/18/2026. Deficiency cited under Regulation 87705(e)(7) is being cleared today during visit. Plan of Corrections Letter provided. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, Plan of Corrections, Appeal Rights, Plan of Corrections Letter, and LIC811 (Confidential Names) discussed and provided to Executive Director. Signature on form confirms receipt of documents.