Incident investigation·April 21, 2026

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a case management visit and gather information/records regarding incidents on 4/19/2026 self reported by the facility on 4/20/2026 that involved staff S1, S2, S3 and residents R1 and R2. LPA met with Executive Director Blaine Lyons, took statement and requested records for Community Care Licensing to review incident. LPA reviewed video surveillance footage of the common area in the Memory Care Unit from 04/19/2026 and observed staff S1, S2 and S3 caring for residents including R1 and R2. The video shows that during the shift S1 employed the use of a bench to prevent R1 from moving off of couch and S2 and S3 moving R2 to a wheelchair and using a seatbelt to secure R2 to chair. While these restraints were used residents were continually being cared for and supervised by staff. It was observed that the restraints were removed at the arrival of the AM shift by staff S4. LPA inspected the Memory Care Unit of the facility and found it to be clean and a comfortable temperature, with protocols in place for safe Dementia Care, including no access to hazardous materials, toxins or sharps and no use of unauthorized restraints. LPA and Executive Director discussed ongoing training with staff. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with licensee and a copy of this report was given.