Incident investigation·April 21, 2026

This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Ruth Martinez to follow up on an incident reported to Community Care Licensing. LPA met with Geno Koehler, Executive Director and Autumn Conquest, Assistant Executive Director and explained the purpose of today’s visit. Incident was self-reported on April 09, 2026, regarding resident (R1’s) incidents on April 07, 2026. Staff indicated that R1 is an independent resident at the facility. On April 07, 2026, at 4:21pm R1 was observed to be having a difficult time walking in the hallway by staff. R1 complained of pain and unable to continue walking. R1 was assisted to a chair and staff immediately called paramedics. R1 was sent out to the hospital for evaluation and staff learned at a later time that R1 had injury to their left hip and under went surgery. R1 was sent to a skilled nursing for recovery once they were discharged from the hospital. R1 is currently at a skilled nursing facility until further notice. Staff upon review of the common space cameras in the hallway noted that R1 was seen walking in the hallways and turned the corner where there is a blind spot from the camera and it looks as though R1 tripped and fell to the ground. Staff was unable to determine the cause of the fall and R1 had very little information to give of the cause. R1 does not require any assisted devices for ambulating in the facility. R1 was last assessed for any changes on October 29, 2025 and does not reflect to be a fall risk or needing assisted devices for ambulating. Care plan dated October 29, 2025 does not reflect R1 to need ambulation assistance or additional services. R1's physicians report reflects that R1 is independent and does not require any assisted devices or have a motor impairment. R1's assessments Continued on LIC809-C do not reflect that R1 is a fall risk. Facility will reassess R1 upon return the facility for any changes in condition and to determine if R1 requires additional care services. 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.