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 12/1/25 in which it was reported that on 11/26/25, an Independent Living Resident (identified as R1), contacted the facility's reception through their pull cord. Upon arrival, staff noted R1 on the floor between their bathroom and bed. Per the report, R1 verbalized that they had hit their head and presented with disorientation. Resident was transported to the hospital by emergency services where they were diagnosed with a closed head injury and shoulder injury. Resident returned to the facility's Skilled Nursing Facility (SNF) for rehabilitation. During today's visit, LPA conducted interviews and file review. Additionally, LPA conducted a visit with R1 and interview did not reveal any licensing or regulatory concerns. File review of R1's records reveal that R1 was part of the independent living community of the facility. As the facility responded accordingly once notified of the incident and arranged for proper and prompt medical care, no violations were observed during today's visit and no deficiencies cited. 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.