Follow-up on corrections·March 10, 2026

LPA Johnson arrived at the care facility and met with Amber to conduct a case management visit into incident reports received on 02/23/2026 and 02/27/2026. Later joined by Jenna Silva Administrator. R-1 AWOL'd from the facility on 2/23/2026 at approximately 7:15 am, Staff members noticed while breakfast preparation and shift change, staff observed that the resident was not present in the common areas as expected. Contact was made to the Licensee/owner by staff members on duty after being unable to locate R-1. R-1 was located by SJC Sheriff on 2/24/2026 and taken to mental health. Staff member returned R-1 back to the facility on 2/24/2026 that morning. According to R-1's Physicians report, R-1 is not allowed to leave the facility unassisted due to poor judgement and the lack of ability to make safe sound decisions. LPA spoke with Staff about the facilities care plan for R-1 going forward. LPA obtained copies of resident's service plan and other pertinent information. Additionally, On 02/27/2026 at approximately 11:30 p.m., staff member S-1, assigned to the NOC shift, reported that R-2 was exhibiting increased agitation and restlessness. The resident was reported to be removing clothing, pulling at his brief, and handling bowel movement contents. Staff reported that the resident was not willing to remain in bed. The behavior was reported to CEO Gloria Murphy at approximately the same time. Hospice of San Joaquin was contacted to assist with medication administration and to assess for any change in the resident’s mental condition. Hospice nurse arrived at approximately 6:30 a.m. on 02/28/2026. This was seven hours after the initial call, upon arrival, the hospice nurse observed the resident (R-2) undressed and on the floor with a floor mat in place. The hospice nurse reported that the resident was assessed for possible trauma or injury, including hip injury. Per hospice nurse assessment, no signs of fracture or acute injury were identified; however, redness was noted on the resident’s right hip and buttock area. At approximately 7:00 a.m., S-2 began their shift and assisted the hospice nurse with cleaning and repositioning the resident. It should be noted that S-1 did assist R-2 during and through out the evening, however, R-2 was aggressive and did not let S-1 completely clean R-2 during multiple changing of R-2's briefs. As a reminder: For emergencies NOT directly related to the expected course of the resident’s terminal illness, the facility staff is required to call 911. Deficiencies were cited on today's date. Exit interview conducted.