Incident investigation·January 26, 2026

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced Case Management visit to follow-up on an Unusual Incident Report received in the Regional Office on January 24, 2026. LPA was greeted and granted entry by the Concierge at 3pm. LPA met with Executive Director (ED) Tonya Reynolds and explained the purpose of the visit. LPA reviewed Resident #1 (R1's) last two medical assessments dated November 18, 2025 and January 31, 2023. R1 is an independent resident who can ambulate but has a call pendant in case of an emergency On January 21, 2026 at approximately 5:30am, the resident had an unwitnessed fall in the bathroom and was not wearing the call pendant at the time of the fall. Staff discovered resident and immediately called 911. R1's diagnoses include: right superior and inferior pubic ramus, tremors and, osteoporosis. R1 does not have a history of falls. Emergency room evaluation reported resident had a right leg fracture. R1 remains at the hospital at this time. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Executive Director (ED) Tonya Reynolds and a copy of the report LIC 811 were given at the time of the visit.