Incident investigation·October 3, 2025

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced case management visit and met with Executive Director, Susan Lee The purpose of the visit was to follow up on two incident reports received by Community Care Licensing (CCL) regarding the same resident (R1), who resided in the facility’s memory care unit. The first report, dated September 29, 2025, indicated that R1 complained of shoulder pain and was transported to a nearby hospital for evaluation. The second report, received by CCL on October 3, 2025, was a death report for R1. According to the report, the hospital disclosed the cause of death only to the family and not to the facility. During the visit, LPA toured the interior and exterior of the facility, reviewed R1’s file, and obtained the most recent hospital discharge paperwork along with the physician’s report and care plan. No immediate health or safety concerns were observed during the visit. No deficiencies were cited at this time. An exit interview was conducted, and a copy of this report was provided to the facility.