Incident investigation·November 25, 2025

Licensing Program Analysts (LPA) Amy Rodgers  conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Chris Neale. During today’s visit, LPA performed a facility tour, collected pertinent records, and interviewed relevant staff. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 11/24/2025), involving Resident #1 (R1) being sent to the hospital for an ankle pain, returning the same day [See LIC 811 Confidential Names List for a description of C1.  According to the physicians' report, R1 ambulates with a walker.  According to care notes and staff interviews, R1 did not report any ankle pain or swelling prior to the incident. Staff confirmed that no limping was observed prior to the incident. R1 is typically only seen going to the dining room and returning to her room, with limited interaction with other residents. LPA observed that R1’s room is located just a few feet from the dining area. No deficiencies were cited during today’s visit. An exit interview was conducted with ED Neale, 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.