Facility Evaluation Report

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Katrina Jimenez and Health Services Director Leah Adolfo.

Today's visit was in response to an LIC624 Incident Report, which Licensee self-submitted to the CCLD San Diego Regional Office (received on 02/02/2026). Per this LIC624, Resident #1 (R1) had an unwitnessed fall on 01/31/2026, and facility staff subsequently sent R1 to local hospital emergency room (ER) on 02/01/2026. [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, LPA performed a brief facility tour / welfare check on R1, collected and reviewed relevant care and medical records, and interviewed R1 and multiple pertinent facility staff. Due to their Alzheimer’s Disease diagnosis, R1 was not a reliable historian. However, records and staff interviews taken together showed:

On 01/31/2026, R1 fell three (3) times inside their bedroom within one day, at around 11:50 AM, 1:00 PM, and 6:21 PM, respectively. The 11:50 AM fall did not involve any suspected injury. The 1:00 PM fall involved a bump on head, for which 911 paramedics responded, but for which R1 and their responsible person also declined transport to the hospital. The 6:21 PM fall involved pronounced pain to R1’s right shoulder area, which was immediately apparent to responding facility staff. Rather than call 911 again for R1, staff assisted R1 to bed and alerted R1’s hospice agency. Facility staff provided R1 as-needed morphine for pain, and the hospice agency dispatched a nurse a few hours later to perform a follow up visit on R1.