Incident investigation·November 20, 2025

Licensing Program Analyst (LPA), Alviso, conducted a case management inspection and met with Interim Administrator Omar Mendoza. Interim Administrator is coming in to help ensure administrator coverage, and facility's plan of operation. Interim Administrator is Case management is being conducted to obtain more information on a resident incident report. R1 had a fall and hit their head; Facility staff didn't contact 911 for R1, to ensure a medical professional assesses the resident's head injury. LPA provided the Department's PIN 25-06 by email to the facility administration staff. The resident is on hospice care, but for emergencies not directly related to the expected course of the resident's terminal illness, the facility staff shall immediately telephone emergency response (9-1-1). Per review of information provided by the Administrator, it is the facility's policy and procedure that staff would contact 911 regarding the above incident of R1. Interim Administrator provided proof of training all staff, including facility management/administration staff, in the facility on "managing medical emergencies." There is sufficient information obtained to support that a violation occurred. Facility staff failed to contact 911 for R1, after resident fell and hit their head. This deficiency will be cited, 87465(g) Incidental Medical and Dental Care-The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2) , (c)(3), or (c)(4) . Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights provided . Exit interview conducted with the Interim Administrator, Omar Mendoza.