Incident investigation·November 24, 2025

This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Ruth Martinez is conducting this case management visit to follow up on an incident reported to Community Care Licensing. LPA met with Autumn Conquest, Assistant Executive Director and explained the purpose of today’s visit. Incident was self-reported on November 18, 2025, regarding resident (R1’s) incidents on November 16, 2025. R1 resides in the memory care unit. On November 16, 2025, at 5:20am staff heard crying coming from R1's bedroom. Staff went in to check on R1 and R1 was found on the floor of their bedroom. Staff noted that R1 had a bump and laceration on their forehead. R1 was complaining of pain to their left arm. Staff immediately called 911 and R1 was sent out to the hospital for further evaluation. Staff notified R1’s primary care physician and R1’s responsible party. Since R1 is in the memory care unit they do not have a pendant, the memory care unit is set up of four cottages with 10 private bedrooms with 10 residents per cottage. Each cottage has one staff for NOC shift and does continuous rounds to check in on residents. The cottages are small premises where staff can hear any resident clearly. Records reflect that R1 walks on their own when in the cottage but require assistance when going on walks in the courtyard or on a community outing. R1 is not a fall risk and the last fall incident was back in February of 2025. R1 returned the same day back to the facility with instruction to follow up with an orthopedic specialist. R1's responsible party is handling follow up appointments. LPA found that facility acted appropriately and in a timely manner to address the incident. LPA did not observe any immediate and/or safety risks in or out of the facility. Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations . This report was reviewed with facility representative, and a copy of the report was furnished to the facility.