Incident investigation·March 13, 2026

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator (ADM) Radhika Martinez. The purpose of the visit was to follow up on two incidents reported by the facility via Unusual Incident/Injury Report (IR). The first IR was submitted on 02/20/2026 and stated that on 02/20/2026, resident R1 exited the facility via a stairwell exit door. R1 was wearing a bracelet that allowed staff to locate him/her. The bracelet indicated that R1 was about a block away from the facility. Facility staff located R1 and escorted R1 back to the facility. During visit on 03/13/2026, LPA Marrufo interviewed Administrator (ADM) Radhika Martinez. ADM stated that R1 lives in the Assisted Living portion of the facility. ADM stated that during the incident, staff were alerted that an exit door had been used and immediately conducted a head count of the residents. ADM stated staff realized after the head count that R1 was missing from the facility and continued to search for R1 within the facility instead of alerting management. ADM stated management staff later used a mobile application that identified the location of R1’s bracelet. R1 was found about a block away from the facility. ADM stated that staff have been trained in-service to immediately utilize the mobile application that identifies the residents’ locations using their bracelets. See LIC809-C page for more information. Page 1 of 2. During visit on 03/13/2026, LPA Marrufo obtained a copy of R1’s Physician’s Report. The Cognitive Conditions section of R1’s Physician’s Report states it is “unknown at this time” if R1 has Mild Cognitive Impairment and “unknown at this time” if R1 has Dementia/Major Neurocognitive Disorder. The Physician’s Report states that if R1 had dementia, R1 does not require supervision when leaving the property due to dementia or cognitive decline. R1’s Physician’s Report states R1 does not have disorientation, unsafe wandering, elopement, or sundowning behavior. The second IR was submitted on 12/12/2025 about an incident that occurred on 12/09/2025 involving staff S1 giving R2 medications M1-M6, which belong to R3. S1 stated R2 and R3 have a similar physical appearance and S1 mistook R2 for R3. Facility staff informed R2’s physician and family and sent R2 to the hospital as a precaution. During visit, ADM stated that every resident’s Medication Administration Record (MAR) has a photograph of the resident. ADM stated to have trained staff to verify the identity of the resident by using the photograph in the resident’s MAR and by asking the resident for his or her name prior to assisting a resident with administering medications. ADM stated that S1 checked R2’s photograph and asked R2 to verify his/her name, but R2 did not respond. ADM stated staff have been trained to ask another staff to verify the resident’s identity if the resident does not respond to a staff member’s request to verify his/her name. On 03/13/2026, LPA Marrufo obtained a copy of R2’s Physician’s Report, which states R2 is not able to administer his/her own prescription medications. 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 Administrator Radhika Martinez and a copy of this report and appeal rights were provided. Page 2 of 2. END REPORT