Incident investigation·January 2, 2026

On 1-2-26 Licensing Program Analyst LPA Sarah Benson arrived at the facility unannounced to conduct a case management visit. LPA Benson met with Administrator Cindy Conley Pacheco and explained the purpose of the visit. The department is following up on an incident report sent by the facility on 12-29-25 stating that a resident, R1 had a un-witnessed fall with a broken hip requiring surgery. The LPA performed interviews and records were reviewed. LPA Benson and Administrator toured the facility together. LPA Benson observed the repair to the dinning room ceiling was completed and the pull cords in memory care are all working. When testing the pull cords it was discovered the pager was not working. The staff used a screw driver to repair the pager during LPA's visit. It was discovered the floors in the residents rooms were not clean. The following deficiencies are being cited on the attached LIC809-D in accordance with California Code of Regulations, (Title 22). Exit interview completed and a copy with appeal rights was given to the administrator. Exit interview conducted and copy of the report left with the administrator.