Follow-up·March 10, 2026

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management visit in regards to two Death Reports received by the Department from the facility for resident R1 and R2 and deliver an immediate exclusion letter for an individual (S1) . LPA met with Interim Executive Director (ED) Brenda Ritter and stated the purpose of the visit. During today's visit, LPA Rai conducted an initial follow up on a Death Report for resident (R1). On 03/09/2026, the Department received a Death Report for resident (R1) who passed away at the facility on 03/01/2026. Based on Death Report, facility staff found resident on the floor and facility staff called 911 and paramedics arrived at the scene. During today's visit, LPA Rai obtained the following documents of R1 which include but not limited to R1's Appraisal/Needs and Services Plan, Physician's Reports and Progress Notes. At this time, this case is under review and the Department will conduct a follow up visit, if warranted. During today's visit, LPA Rai hand deliver an immediate exclusion letter for an individual (S1) who the Department determined engaged in conduct inimical as a staff in the facility. The letter was handed to the Interim Executive Director (ED) Brenda Ritter . ED stated the facilty records show S1 was not employed by the facility, therefore S1 was not present at the facility. ED stated they will ensure all staff prior to working at the facility will o btain a California clearance or a criminal record exemption. ED agreed and understood. During today's visit, LPA Rai conducted a follow up on a Death Report for resident (R2). On 6/23/2025, the Department conducted a case management visit to follow up on Incident Report/Death Report for resident (R2) who sustained an injury from an unwitnessed fall and passed away at the hospital. Continuation on LIC 809-C, Page 1 of 3. Page 2 of 3. The Department received an Incident Report for an incident which occurred on 6/20/2025 wherein R2 had an unwitnessed fall in resident's room in the Memory Care unit. R2 stated the right side of the body and head was "hurting". The facility staff called the paramedics and R2 was taken to the hospital. The Department received a Death Report wherein R2 passed away at the hospital on 6/20/2025 and the immediate cause of death is unknown. On 12/19/2025, the Department interviewed two staff (S2-S3). Two out of two staff stated the residents are checked on by staff every hour for safety, but they do not document their safety checks. S2 stated the residents in the memory care units do not have call buttons or alarm pendants and the residents will verbally call for staff if they require assistance. Two out of two staff stated resident R2 was a fall risk resident. On 12/24/2025, the Department interviewed four residents (R3-R6). Four out of four residents stated they feel safe at the facility and do not have any complaints. On 12/24/2025, the Department interviewed three staff (S4-S6). Three out of three staff stated the residents are checked on by staff every hour for safety, but they do not document their safety checks. Three out of three staff stated the resident R2 was a fall risk resident. S4 stated he/she checked on R2 the day of the incident on 6/20/2025 wherein R2 was calling for help in the room and S4 found R2 on the floor. S4 stated R2 was trying to put on clothes when R2 fell on the floor. S4 stated R2 was assessed R2 and called 911 and the paramedics transported R2 to the hospital. S4 stated R2 was checked an hour before the fall incident on 6/20/2025 and R2 was in bed sleeping. S5 stated R2 and R2’s family was recommended for a private companion but R2’s family refused. On 1/7/2025, the Department interviewed 1 staff (S6). S6 stated he/she assessed resident R2 on 6/20/2025 and found R2 on the floor of the room. S6 stated R2 complaining of pain on the right side of rib area. S6 called 911 as a response to R2’s fall. S6 stated resident R2 was a fall risk resident. On 2/2/2026, the Department interviewed physician (P1) from Santa Clara County’s office. P1 stated the rib fracture complicated R2’s underlying chronic diseases and contributed to R2’s death. P1 stated the trauma from the injury placed too much stress on R2’s body. Page 3 of 3. On 2/3/2026, the Department interviewed 1 staff (S5) to further clarify information provided on 12/24/2025. S5 stated residents are determined to be fall risk using the facility’s fall risk assessment tool. S5 stated the facility staff provided assistance with resident R2’s activities of daily living (ADLs), checked on resident R2 frequently and reassessed every time R2 has a fall. S5 stated the facility staff was concerned about R2’s fall incidents where S5 spoke to R2’s family and recommended a private caregiver but R2’s family refused due to the cost. Based on review of R2’s assessments after 11 documented falls from 5/24/2025 to 6/20/2025, the assessments would evaluate R2’s condition at the time of each incident but it did not result in documented revisions, modifications, or escalation of the care plan. According to R2’s gait analysis, R2 had a loss of balance while standing, and had decrease in muscle coordination. R2 used an assisted device and required assistance when moving from place to place. R2 was noted to be between a moderate to high fall risk. Based on review of R2’s Service Plan Report dated 4/9/2025, the report included fall prevention measures. The facility staff documented on R2’s progress notes from 5/24/2025 to 6/20/2025, R2 had 11 witnessed and unwitnessed falls in the facility. R2’s Service Plan dated 4/9/2025 remained on file and the facility staff did not update R2’s fall prevention plan after having 11 documented falls. Based on review of R2’s Death Certificate, R2’s immediate cause of death was due to a rib fracture complicating neurodegenerative disease. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Interim Executive Director (ED) Brenda Ritter and a copy of the report was provided. Appeal Rights was provided.