Incident investigation·October 9, 2025

On 10/09/25, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding incidents related to resident, R1. LPA met with Administrator Emanuel Dirar and explained the reason for visit. Incident Report (LIC 624) submitted by facility on 09/27/25 to CCL stated that R1 had a fall on 9/11/25 was sent out to local hospital and diagnosed with fracture of 5th metacarpal. R1 returned to the facility presented with increased confusion and pain when standing. R1s primary care physician (PCP) advised for resident to be sent out for further evaluation on 9/19/25. Staff sent out R1 to hospital per PCP directions. It was learnt that R1 was sent to skilled nursing facility for rehab services per their PCP’s orders and R1 did not return to facility as of today. Based on incident report, staff interviews and record review from the facility, it was determined that facility did not report R1s fall and injury related incident from 09/11/25 in timely manner to CCL as required per Reporting Requirements. Based on gathered information, deficiencies are cited pursuant to California Code of Regulations, Title 22, Section 87211 and documented on the attached LIC809D. Civil penalties may be assessed if facility does not comply with POC requirements which were issued today. Exit interview was conducted, copy of the report and appeal rights were provided.