Incident investigation·April 10, 2026

Licensing Program Analyst conducted an unannounced case management visit regarding the incident report received on 04/10/2026. LPA met with Associate Executive Director (AED) Valerie Baldugo and stated the purpose of the visit. The facility is licensed to serve adults age 60 and over, 140 non-ambulatory, of which 21 may be bedridden and hospice waiver for 15. LPA conducted an interview with the AED (S1) and Memory Care Director (MCD) (S2), and inquired about the incident that happened between two residents. The incident was reported by the facility to CCLD and states that resident 1 (R1) (diagnosis: dementia/Major NCD) stated that resident 2 (R2) and roommate (diagnosis: dementia/Major NCD) hit R1 with a book during the overnight hours of 04/08/2026 into the early morning of 04/09/2026. Both residents reside in memory care. Staff 3 (S3) was present, and observed R2 in bed throughout the night asleep. Memory Care Director (MCD/S2), assessed R1 and did not observe any injuries on R1 head. MCD/S2 observed and noted that there were no books in the apartment. R1s family was offered an upcoming private suite but declined due to financial concern. LPA requested documents for 2 out of 2 residents such as but not limited to physician's report (LIC 602), and individual care plan. LPA conducted a site inspection and during the site inspection, LPA was met with R1's spouse and child who resides in a different country and was on a video call with his/her parents. LPA was able to interview R1 and provided additional information. LPA met R2 but was not able to answer questions. S1 stated that a plan to move R1 or R2 to a different room is being considered. At this time, this case in under review and department will conduct a follow up visit, if warranted. No deficiencies cited during today's case management visit based on CCR Title 22. A copy of the report was provided to AED Valerie Baldugo.