Incident investigation·February 4, 2026

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Katrina Jimenez and Health Services Director Leah Adolfo. Today's visit was in response to an LIC624 Incident Report, which Licensee self-submitted to the CCLD San Diego Regional Office (received on 02/02/2026). Per this LIC624, Resident #1 (R1) had an unwitnessed fall on 01/31/2026, and facility staff subsequently sent R1 to local hospital emergency room (ER) on 02/01/2026. [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. During today’s visit, LPA performed a brief facility tour / welfare check on R1, collected and reviewed relevant care and medical records, and interviewed R1 and multiple pertinent facility staff. Due to their Alzheimer’s Disease diagnosis, R1 was not a reliable historian. However, records and staff interviews taken together showed: On 01/31/2026, R1 fell three (3) times inside their bedroom within one day, at around 11:50 AM, 1:00 PM, and 6:21 PM, respectively. The 11:50 AM fall did not involve any suspected injury. The 1:00 PM fall involved a bump on head, for which 911 paramedics responded, but for which R1 and their responsible person also declined transport to the hospital. The 6:21 PM fall involved pronounced pain to R1’s right shoulder area, which was immediately apparent to responding facility staff. Rather than call 911 again for R1, staff assisted R1 to bed and alerted R1’s hospice agency. Facility staff provided R1 as-needed morphine for pain, and the hospice agency dispatched a nurse a few hours later to perform a follow up visit on R1. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] However, by the morning of 02/01/2026, R1 remained in pain, and their right shoulder area was now significantly discolored, so staff arranged for R1 to be transported to the hospital ER; R1 departed the facility around 11:03 AM. Per hospital ER records, R1 was diagnosed with a new “closed displaced comminuted fracture of shaft of right humerus.” (A comminuted fracture is a type of injury where the bone breaks in multiple places. A displaced fracture means the fragments have moved out of normal anatomical alignment, creating a gap or misalignment.) CCR 87465(g) requires Licensees to “immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health.” Regarding residents receiving hospice care, CCR 87469(c)(3) specifies, “For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1).” CCLD concluded that the injury to R1’s right shoulder/arm was serious and required staff to call 9-1-1. This injury also was not related to the expected course of R1’s underlying terminal illness/diagnosis. To date: The available evidence did not clearly show that Licensee’s delay in activating 911 worsened R1's injury. The available evidence also showed that Licensee had performed Care Plan updates/reappraisals on R1 in the past, as required. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Executive Director Katrina Jimenez and Health Services Director Leah Adolfo, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.