Incident investigation·December 26, 2025

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 Heather Myers. LPA also met with Business Office Manager Jessica Mallory. Today's visit was in response to three (3) written reports which Licensee self-submitted; all were received at the CCLD San Diego Regional Office on 12/24/2025. The first was an LIC624 Incident Report, describing an altercation between Resident #1 (R1) and Resident #2 (R2) on 12/09/2025, for which R1 was medically cleared at the emergency room. The second was an LIC624 Incident Report, describing R1 having an unwitnessed fall in their bedroom on 12/11/2025, for which R1 required hospitalization. The third was an LIC624A Death Report, which described R1 passing away at the hospital on 12/17/2025. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report]. During today’s visit, LPA performed a brief facility tour and welfare check on R2 and other residents in care. LPA interviewed facility managers and collected copies of pertinent care records on R1 and R2. Per interview of the facility administrator: Hospital staff reported that R1 was very agitated while at the hospital, requiring physical restraints and new medications, and that R1 had refused to eat food and drink by mouth, from 12/12/2025 until they died on 12/17/2025. LPA also audited the facility’s employee roster against CDSS’ Guadian System. LPA observed, and manager interviews confirmed: One (1) of one-hundred (100) employes, Staff #1 (S1), did not have a Criminal Background Clearance to work, as required. Records showed S1 was a per-diem employee who was hired on 01/10/2025. Per phone interview of S1, they had worked more than five (5) days at the facility since then. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] One (1) deficiency was cited today per California Code of Regulations, Title 22 (see the attached LIC809-D page). Since the violation was regarding a staff background clearance, and immediate civil penalty of $500 was assessed (refer to the LIC421-BG page). A Plan of Correction were jointly formed with the Licensee. An exit interview was conducted with Executive Director Heather Myers, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.