Incident investigation·December 22, 2025

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director (ED) Stefanie Thune-Barnes and Health Services Administrator Brooke Patterson. Director of Residential Health Shila Jurado and Residential Administrator Tyre Richards joined later during the visit. Community Care Licensing received an Incident Report on 11/3/25 in which it was reported that on 10/31/25, a memory care Resident (identified as R1), was noted to have small sores behind their knee due to a below the knee splint from a prior injury. Resident was transported to the hospital where they were treated for the injury and the skin assessed. Per the report, R1 returned to the facility same day and that their prior leg injury was stable. R1's responsible party and primary care physician were notified. During today's visit, LPA conducted interviews and file review. Additionally, LPA conducted a visit with R1. Due to time constraints, LPA was unable to complete a determination regarding this case management visit, and additional visits may be necessary to complete review of this incident. At this time, LPA observed no health and/or safety concerns and no deficiencies were cited during today's visit. An exit interview was conducted with Residential Administrator Richards to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.