Incident investigation·December 2, 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 12/1/2025), involving Resident #1 (R1) being sent to the hospital for a fall and facial injury. According to the care assessment (dated 7/23/2025), R1 use a wheelchair and walker to ambulate. According to care notes and staff interviews, most of the previous falls were minor and occurred during independent transfers from bed to wheelchair or chair to wheelchair, as well as during attempts to ambulate without assisted devices to the restroom, which is located just a few steps from his bed. Outside Source #1(OS1) confirmed that no limping or stumbling was observed prior to the incident and R1 was walking from the restroom without an assisted device. Outside Source #1(OS1) reports they witnessed the fall and they reported R1 seemed to have passed out while walking and fell face first on the floor. The incident was reported immediately to staff and emergency services were called as protocol. 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.