Facility Evaluation Report

Licensing Program Analyst (LPA), Amy Rodgers, conducted an unannounced visit to initiate a case management visit. LPA Rodgers identified herself and was granted entry by concierge Jacqueline Aceves. LPA Rodgers stated the purpose of the visit and reviewed the basic elements of the visit with Associate Executive Director Aileen Spence.

This visit is in response to an Unusual Incident/Injury Report (IR) that was received at the San Diego Regional Office on November 21, 2025. The IR stated that there was an incident that transpired on Monday, November 15, 2025, with resident #1 (R1 – see LIC811 for confidential names list) displaying aggressive behaviors with visiting family members. The facility made notifications to R1’s responsible party, their Medical Doctor (MD), and the Department.

During today's visit LPA Rodgers briefly toured the facility, spoke with staff and observed R1, and requested and obtained relevant documents pertinent to this incident. LPA Rodgers verified R1's service plan was updated on 11/21/2024 and again on 11/24/2025. Per their latest LIC602 Physician’s Report (dated 05/19/2025), R1 was diagnosed with “Lewy Body Dementia” and required staff assistance with taking their prescribed medications. Care notes were also obtained and the Department verified staff have been taking appropriate measure to deescalate R1 and observe triggers that may cause behaviors.

No Citations or Deficiencies were issued during the visit.

An exit interview was conducted with Associate Executive Director Aileen Spence, and a copy of this report, LIC811 and Licensee Appeal Rights (LIC9058) were provided at the conclusion of the visit. The signature below confirms that the documents were received.