Incident investigation·January 29, 2026

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Jennifer Duenas, Sales Operations Support. LPA stated the reason for today's inspection was to discuss (1) incident report recently submitted to the Department involving resident (R1). LPA and RCC discussed the incident when (R1) had an unwitnessed fall in their room on January 24, 2026. (R1) complained of pain in their mid-back and neck and was went out for further medical attention. (R1) was admitted to the hospital with a diagnosis of a pelvic fracture with possible surgery. The next day the hospital advised the facility surgery would be performed. At this time, the facility is waiting for an update on (R1's) recovery status and when they will return to the community. The Sales Operations Support manager stated that (R1) is continuously walking throughout the day when not sleeping and refuses to use a walker. The facility will request an updated physician's report since the resident has been out of the community for more than (3) days and will update the care plan as needed. LPA obtained a copy of (R1's) current physician's report and care plan during today's inspection. Also discussed today was the recent hospice passing of resident (R2). The Department received a completed LIC624A yesterday falling resident's passing. The facility will submit an amended death report as the date of death was incorrectly reported as December 14, 2025. LPA conducted a brief health and safety inspection to observe residents in care. LPA observed many residents attending a communal birthday celebration. There are no citations in this report. Exit interview. Copy of report provided.