Facility Evaluation Report

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Wesley Lavender, Executive Director.

Today's visit was in response to Licensee’s self-reported incident report, received at the CCLD San Diego Regional Office on 06/24/2026. [See LIC 811 Confidential Names List for a description of Resident 1(R1)]. During today’s visit, LPA briefly toured the facility, collected and reviewed care records on R1, and interviewed staff. LPA performed a cursory welfare check on the remaining residents in care, finding no immediate safety concerns. Interviews of staff showed: R1 lived at the facility since 05/31/2023. R1 also has a private caregiver since they returned from the hospital in January 2026. R1 sustained a fall with a hip fracture in November 2025 and was out of the facility until January and the family had a private duty with R1 since. This incident occurred on 06/12/2026, R1 had a witnessed, assisted fall while going to the bathroom, meaning the private caregiver assisted the resident down to the floor. It was noted that R1 did not have any pain or injury on that day. Interviews revealed that the resident's POA on file was notified. Interviews revealed the private caregiver advised staff of the fall on that day immediately after it happened. On 06/15/2026 R1 reported having lower back pain and resident was transported to ER by non-emergency transport and was evaluated by the hospital team and admitted for observation and treatment of a compression fracture of lumbar vertebrae. Interviews revealed resident stayed at the hospital for 3 days. R1 returned on 06/18/2026. No surgery was completed at this time with new orders of narcotic medication for pain. During a review of records, LPA observed and Executive Director interview confirmed: R1 has been here over 3 years. The completed LIC 602 Physician’s Report on R1,was completed as was required on 01/05/2026. The report stated that R1 requires assistance with repositioning and transferring. No deficiencies observed or cited during todays visit.

An exit interview was conducted with Wesley Lavender, Executive Director , to whom a copy of this report, the LIC 811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.