Incident investigation·January 22, 2026

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report received by the department on 01/16/2025. LPA was greeted and granted entry into the facility and explained the reason for the visit. Incident report dated 01/09/2025 indicated Resident 1 (R1) was found on the floor in the resident's room with a noticeable bump on the head. Hospice was notified and staff state there were no injuries from the fall. Resident is noted to be a fall risk per facility assessment. In conjunction with complaint visit 22-AS-20260114091113, LPA reviewed records. Facility did not submit an incident report for the incident noted in the complaint where R2 was found locked outside the facility. Based on the observations made during today’s visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.