Other·April 1, 2026

Initial Comments The following reflects the findings of the California Department of Public Health (CDPH) during an investigation of an entity reported incident or complaint. ACTS Intake Number: CA00962321 Substantiated The investigation was limited to the specific events reported and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyor#: 49810 Health and Safety Code 1280.15(b)(1) – Tag 180 Late reporting to the Department. This Statute is not met as evidenced by: Based on correspondence, interviews, and record reviews, the facility failed to report the unlawful or unauthorized access to, and use or disclosure of, patient (PT1) medical information, to the CDPH within 15 business days from date of breach detection by the facility on April 16, 2025. Facility notified the CDPH of the breach on May 14, 2025, which is seven days late. Findings: On May 14, 2025, the facility reported a potential breach of confidential medical information to the California Department of Public Health (CDPH). The incident’s occurred on January 3, 2025, and January 9, 2025, and was detected by the facility on April 16, 2025. On December 11, 2025, CDPH reviewed written notification of the breach from facility to the CDPH. Review confirmed that facility notification was dated May 14, 2025, and that the breach was detected on April 16, 2025 , which validates the notice being seven days late. Health and Safety Code 1280.15(b)(2) – Tag 190 Late reporting to the affected patient or the patient's representative. This Statute is not met as evidenced by: Based on correspondence, interviews, and record reviews, the facility failed to report unlawful or unauthorized access to, and use or disclosure of, patient (PT1) medical information, to the affected patient within 15 business days from date of the breach detection. Facility detected the breach of PT1’s medical information on April 16, 2025, and notified PT1 on May 9, 2025, which is two days late. Findings: On May 14, 2025, the facility reported a potential breach of confidential medical information to the California Department of Public Health (CDPH). The incident’s occurred on January 3, 2025, and January 9, 2025, and was detected by the facility on April 16, 2025. On December 11, 2025, CDPH reviewed written notification of the breach from the facility to PT1. Review confirmed that the notification to PT1 was dated May 9, 2025. On December 2, 2025, CDPH confirmed via an interview with the facility’s Compliance and Privacy Officer that the breach was detected on April 16, 2025, which validates the notice being two days late.