Incident investigation·August 15, 2025

Licensing Program Analyst (LPA) David Roman conducted an unannounced case management inspection visit. LPA D. Roman identified himself to Facility Manager, Gabriela Zamora, and discussed the purpose of the visit. LPA D. Roman along with facility staff toured the interior and exterior of the facility and inspected resident bedrooms. LPA D. Roman interviewed the resident and staff. The facility was sanitary, and in decent repair. LPA inspected the bedroom of the resident in question in which the pathways appeared to be obstructed by ripped linoleum floor covering. LPA D. Roman informed Facility Manager, Gabriela Zamora that the ripped linoleum floor should be removed to avoid future falls for residents in care. Facility Manager, Gabriela Zamora contacted maintenance employee to remove the exposed/ripped linoleum. Pathways throughout the facility were free of obstruction and slip hazards. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. LPA D. Roman completed records review of the resident in question. The resident is receiving medication support services, hospice care, and the resident has a follow up visit with PCP on 08/20/25. An exit interview was conducted with the Facility Manager, Gabriela Zamora to whom a copy of this report and the Licensee/Appeal Rights were provided during the visit.