Incident investigation·October 22, 2025

On 10/22/2025 at 2:05 PM, Licensing Program Analysts (LPAs) P.Manalo and K. Nguyen conducted an unannounced Case Management visit regarding a self-reported incident. Director of Health and Wellness, Judith Gitonga, self-reported the incident on 10/21/2025. LPAs met with Judith Gitonga and explained the purpose of the visit. Executive Director was unavailable during today's visit. LPA P.Manalo received a self-reported incident report from facility that indicated that the Resident 1 (R1) was taken to the hospital for unwitnessed fall and R1 was treated for a hip fracture. R1 had hip surgery and is in a skilled nursing for recovery. The facility will reassess R1 before returning to the facility. During the visit, LPA interviewed Gitonga and stated that R1 had fell in R1's room. LPAs will be requesting for the following documents such as R1's physician's report, previous and new full care plan, staff schedule, progress notes, and care log for R1 by 10/30/2025. LPAs may return at a later time. No deficiencies cited during visit. Exit interview was conducted with Director of Health and Wellness and a copy of this report was provided.