Incident investigation·January 9, 2026

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Riley Tucker and Ben Roedel. The purpose of the visit was to respond to an Incident Report (IR) that the facility submitted to the department on 01/08/2026. The IR stated that on 12/31/2025 at around 9:00 AM, staff S1 was assisting resident R1 to the bathroom. S1 briefly left R1 in the bathroom to provide assistance to another resident. Before leaving R1, S1 told R1 to push the emergency call light inside the bathroom once R1 was done using the bathroom. When S1 returned, S1 found R1 sitting on the floor. S1 told S2, a medication technician, about R1's fall. S1 helped R1 back onto R1's wheelchair safely. S2 noted there was no injury to R1. S2 did not report R1's fall to S2's supervisors. During visit, LPA Marrufo obtained copies of R1's Physician's Report and Appraisal/Needs and Services Plan. R1's Physician's Report states R1 is not able to care for R1's own toileting needs. The Background Information section of R1's Appraisal/Needs and Services Plan states, "[R1] requires the help of one person to complete activities of daily living." The Functional Skills section of R1's Appraisal/Needs and Services Plan states, "Resident requires full assistance with all functional mobility and activities of daily living (ADLs), including bathing, dressing, toileting, feeding, and ambulation, due to physical limitations. Dependent on staff for transfers, repositioning, and mobility." See LIC809-C page for more information. Page 1 of 2. During visit, LPA Marrufo obtained a copy of S1's Corrective/Disciplinary Action Form, dated 01/06/2026. The Corrective/Disciplinary Action Form states, "On Dec. 31 around 9am while assisting the resident in the bathroom, caregiver briefly left because [he/she] was not yet finished and checked the resident in front of [redacted]. When the caregiver returned, [he/she] found the resident sitting on the bathroom floor and informed med tech immediately." The form was signed by S1 and S1's supervisor on 01/06/2026. During visit, LPA Marrufo interviewed R1 and S2. R1 stated during interview to have grabbed the grab bar in the bathroom when he/she fell to the bathroom floor. S2 stated during interview that care givers called S2 into R1's apartment. When S2 arrived, R1 had been positioned into R1's wheelchair near R1's bed. S2 stated to have forgotten to notify S2's supervisors about R1's fall. A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information. An advisory note was issued. See LIC9102 for more information. This report was reviewed with Riley Tucker and Ben Roedel and a copy of this report and appeal rights were provided. Page 2 of 2. END REPORT