Incident investigation·May 5, 2026

On 05/05/2026 at 10:30AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct a case management visit in regard to incident report received on 04/21/2026. LPA met with Caregiver, Merle Guevarra and explained the purpose of the visit. Incident report dated 04/21/2026 revealed that R1's slipped off the bed during brief change, resulting in bruising on left side near ribs on 04/20/2026. S1 was assisting R1 with brief change when R1 fell off the bed. S1 called emergency personnel and R1 were transported to hospital to be examined. During visit, LPA interviewed R1, S1 and S2. LPA also reviewed incident report, R1’s after visit summary dated 04/20/2026-04/22/2026. LPA observed R1’s after visit summary did not indicate any bruising or injury to R1’s left side ribs. No deficiencies were cited during the visit. Exit interview conducted and a copy of this report provided .