Incident investigation·March 14, 2025

On 03/14/2025, at 2:15 PM Licensing Program Analysts (LPAs), P. Manalo and K. Nguyen arrived unannounced to conduct a case management following up an incident that was reported to CCLD on 02/27/2025 regarding R1 obtaining a wound while in the hospital. LPAs met with Director of Health and Wellness, Judith Gitonga, and explained the reason for the visit. LPAs reviewed R1's Physician's Report dated 2022, 2023, and 2025, Senior Living Standard Level of Care and Service Plan, Service Plan Report, Watermark Assessment, Elopement Risk Screening, Outside Agency Documentation, Progress Notes, and Discharge Summary. LPAs interviewed S1 and indicated that they had done an assessment prior to the resident returning back to the facility. LPAs are requesting to obtain Staff Contact information, Staff Schedule, Previous Service Plan Reports, and other notes pertaining to R1's injury (Caregiver's Notes) by 03/19/2025. LPAs will return at a later time. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.