Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management inspection to following up on a self-reported incident submitted to Community Care Licensing and met with Roxana Galo , Licensee . The purpose of this case management inspection is to obtain additional information regarding incident involving resident (R1). LPA reviewed records and conducted interviews.

Per incident report submitted 3/2/2026 reporting R1 had an un-witnessed fall on 2/26/2026. Licensee found R1 in the living room laying down at their left side R1 was bleeding from their head. At 5:00pm, R1’s responsible party arrived at the facility, helped them, checked them, decided not to call 911 and R1 remained in facility. During today’s visit, LPA reviewed R1's physician report dated 8/28/25 and care plan dated 11/22/25 which both do not indicate fall risk, but indicates that R1 had motor impairment left sided weakness due to a history of stroke. According to Licensee, the day of the incident, R1 sustained a small cut, triangle shape in their head, R1's responsible party arrived while the Licensee was assisting R1 after the un-witness fall happened, and R1's responsible party cut R1's hair near the area of the bleeding and applied vaseline, but they declined to call 911. R1's responsible party told the Licensee that they were taking responsibility and willing to sign any documentation certifying that they refused to take R1 to get medical assistance. As of today, R1's physician has not been contacted to notify them about R1's un-witnessed fall. LPA have a conversation with the Licensee about the requirement to follow up their facility plan of operation and regulation 87465 (a)(2) regarding providing medical assistance to a resident after a fall, hit head and bleeding observed.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal Rights Given. Exit interview with Licensee and a copy of this report was given.