Facility Evaluation Report

On 5/1/2026, Licensing Program Analyst (LPA) K.Kaur arrived unannounced for complaint inspection and

conducted a case management in conjunction. LPA met with Administrator Elizabeth Reynaga and Resident Care Director Natalie Levario and introduced self and explained the reason for the visit.

During the course of complaint investigation, the Department discovered Resident (R2) had a fall on 7/8/2025 around 5pm which resulted in hip bone fracture. Resident was in pain and did not allow brief change during NOC shift (11PM – 7AM) per records. Resident was not sent to hospital until 8AM on 7/9/2025.

Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22,

An exit interview was conducted with Administrator including discussing the plan of corrections. Report signed on-site. Printed copy provided with 809D page and appeal rights.