Incident investigation·December 16, 2025

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 12/16/25 to do case management visit to follow up on incidents reported by facility for residents . LPA met with House Manager, Emonnie Rowe (S1) and explained the purpose of the visit. LPA spoke with Administrator, Rebecca Thomas via phone and Administrator gave permission to conduct today's visit with S1 since they were not able to come to facility today. Incident for Resident, R1 - Department followed up on SOC 341 sent by facility on 12/15/25 stating that staff (S) yelled at resident, R1 due to sandwich issue on 12/09/25 and witnessed by other staff and visitors. It was learnt that staff S was no more employed at the facility after that incident. Incident for Resident, R2 - Department followed up on SOC 341 sent by facility on 12/04/25 stating that resident, R2 went to hospital due to change in condition on 11/24/25. R2's family came to facility to collect 2 rings belonged to R2 as R2/family left in R2s room but could not find the rings. Staff did the through search to look for missing rings but were unsuccessful. Incident for Resident, R3 - Department followed up on LIC624/LIC624A sent by facility on 11/26/25 stating that resident, R3 went to hospital due to change in condition on 11/21/25. It was learnt that R3 condition get worsened at the hospital due to R3's cardiac issues and R3 passed away at hospital during hospital care. Facility notified LTCO, local law enforcement and responsible parties regarding these incidents. Department conducted interviews with 1 resident and 2 staff during today's visit. At this time, these incidents are under review and department will do follow up if warranted. No citations were issued per Title 22 Regulations.Exit interview conducted and copy of the report left at facility.