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 9/5/25 in which it was reported that on 9/3/25, a memory care Resident (identified as R1), was discovered on the floor during rounds and that they had sustained an open wound to the back of their head. Per the report, R1 was unable to state how they had fallen. Emergency services were contacted and R1 was taken to the hospital where they received staples to close their wound. R1 was discharged back to the facility same day. Per the report, R1's responsible party, primary care physician, and hospice agency were notified. During today's visit, LPA conducted interviews and file review. A health and safety visit with R1 could not be completed as R1 had passed away shortly after the incident from their hospice diagnosis. 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.