Incident investigation·October 23, 2025

On 10/23/2025 at 3:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit regarding an incident report received by the Department on 12/11/2023 . LPA met with Licensee, Josefina “Penny” Gardner. Licensee later had to leave and provided authorization for Caregiver, Sinforosa Arawiran , to sign the report. LPA explained the purpose of the visit. While LPA was conducting a complaint investigation ( #15-AS-20240202150258 ) on 10/23/2025, LPA sought clarification as to why the night shift staff did not complete an assessment on Resident 1 (R1) after R1 experienced a fall during the early morning hours. Review of the facility’s incident report dated 12/09/2023 revealed that R1 fell at approximately 3:20 AM . The report indicated that Staff 2 (S2) assisted R1 from the floor and placed R1 back into bed. The report also noted that R1 had a history of hip surgery . LPA interviewed Staff 1 (S1) who stated that S2 was able to assist R1 back into bed and completed an assessment by checking for bruising, skin tears, and observing for pain or discomfort. LIC809-C Continued... LIC809-C (Page2) S1 reported that R1 did not display any signs of pain at that time, and therefore S2 did not contact 911. LPA attempted to contact S2 via text message and phone call for further clarification; however, S2 was unavailable for interview. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to the facility representative.