Incident investigation·February 12, 2026

On February 12, 2026, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a follow-up case management visit regarding LPA's visit conducted on January 8, 2026. LPA met with staff and explained the purpose of the visit. Staff contacted Administrator who informed LPA that she was unavailable to meet in person as she is occupied for an assessment at a different facility. During LPA's visit conducted on January 8, 2026, the visit was regarding a death report LPA received which was reported late to Community Care Licensing. Interview was conducted with Administrator on January 8, 2026, which revealed that R1 was observed to be declining for a "couple" of weeks. Observations was reported to R1's responsible party but not to R1's primary care physician. Additionally, file review was conducted which revealed that R1 is on a special diet of pureed textured nectar thick, but this special diet was not followed as R1 did not like the texture. Interview conducted with Administrator and staff conducted on January 8, 2026 revealed that day of R1's death, R1 was provided eggs and scrambled eggs for breakfast. It was discussed over the phone with Administrator when a resident has a change of condition it is to be documented and reported immediately to primary care physician. Additionally, it was discussed over the phone with Administrator that if a special diet was ordered by a physician, facility is to follow and/or report to physician if there is any concerns where the special diet cannot be met. As a result of today's visit, deficiencies were cited. Please see LIC 809-D. Exit interview conducted and a copy of report and appeal rights provided.