Incident investigation·March 13, 2026

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management Visit and met with Roberto Valdebenito, staff. The purpose of the visit was to follow up on an exception request for a Foley Catheter for resident R1 that the facility submitted to the Department on 02/27/2026. On 02/27/2026, LPA Marrufo made a telephone call to Administrator (ADM) Bani Kaur. During the telephone call, ADM stated R1 was admitted to the facility on 02/21/2026. ADM stated R1 was in the hospital prior to being admitted to the facility. LPA Marrufo asked ADM why she had not requested an Exception for R1’s catheter prior to admitting R1 into the facility. ADM stated the hospital discharged R1 without notice over the weekend without notifying her. LPA Marrufo requested that ADM submit a formal request letter requesting an Exception for R1’s Foley Catheter, along with other supporting documents. On 03/11/2026, LPA Marrufo received R1’s Physician’s Report via email from ADM. R1’s Physician’s Report states R1 cannot manage his/her own treatment/medication/equipment and includes a comment “needs verbal cues.” R1’s Physician’s Report states that R1’s cognitive condition is “recent stroke.” During visit, LPA Marrufo conducted a welfare check of the residents and reviewed resident records. There are no residents under the age of 59 years old at the facility. A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information. This report was reviewed with staff Roberto Valdebenito and a copy of this report and appeal rights were provided.