Incident investigation·April 16, 2025

On April 16, 2025, Licensing Program Analyst Manuel Monter conducted a case Management Incident visit regarding an incident report the Department received, stating there was a water leak at the facility. On April 15, 2025, the Department received an incident report that stated, " On 04/13/25 around 10:59 AM, a leak was observed in the elevators. Staff alerted ... Executive Director, Rachel Brown. Elevators stopped on the nearest floor and opened, and were shut down. A plumber, elevator technician, and two water removal/remediation crews were brought on site. The source of the leak was found to be a water holding tank for the boiler, located on the roof. Water flooded into laundry rooms on floors 2-7 and traveled from laundry rooms into elevator doors and 11 resident apartments total, across floors 2-7. Water also impacted the 1st Floor lobby.... Executive Director, who called vendors for urgent assistance. LVN on Duty turned off main water. Vendors stopped flooding, removed water, and worked on drying wet surfaces. Elevator tech assessed elevator operations. Executive Director informed all responsible parties via email and called responsible parties of impacted apartments. Staff transported residents who were in programs back to their apartments via stairs, as directed by LVN on Duty. After removing water, remedial on crews placed fans & dehumidifiers in affected common areas and apartments on 4/13125,Remediation crews will check progress daily until areas are dry" Page 1 Out of 2. On April 16, 2025, Licensing Program Analyst Manuel Monter toured the facility 1-7 floors. LPA observed the areas that were affected by the water leak, which was areas directly next to the laundry rooms on floors 2-7. This water that leaked, traveled from laundry rooms into elevator doors and 11 resident apartments total, across floors 2-7. During the tour, LPA observed fans and dehumidifiers in each floor, and noted there was no smell or current sign of wetness during the tour. LPA interviewed facility Administrator. ADM stated 3 residents who were residing near the area, where the water leaked, moved to different apartments. ADM stated she has been talking to the residents to ensure they are doing well. ADM stated no resident was physically impacted by the water leak. ADM stated the Fans and dehumidifiers will continue to run until the moisture is gone, but stated vendors estimate the completion date by Friday. ADM also stated the water leak effected the elevators control panels. ADM stated the elevators still work, but need to operate manually. ADM stated the control panels for the elevator have been ordered and should arrive at the facility by Saturday, and installed by this Sunday. ADM stated the facility is assisting residents go down the to first floor by; the facility will manually operate the elevator, via the key and will escort residents down. ADM stated because the panels on the elevator are not functioning, they need to use a key to manually operate it. ADM stated her plan of action to address the leak and wet areas is the facility will be evaluating the tank. ADM stated they will assess the tank to see if they can reinforce the tank, as a temporary measure to ensure a leak does not re occur in the short term. ADM stated the facility is planing on replacing both hot water tanks. ADM stated her plan of action to ensure the health and safety of residents in care, is to continue to deliver meals. ADM stated once the elevator panel is fixed sometime this weekend, dinning can open for residents in the weekend. ADM stated she is staying in contact with the residents, asking how they are doing and family's to keep them updated on the ongoing process. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Rachel Brown and a copy of the report was provided. Page 2 Out of 2.