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 11/12/25 in which it was reported that on 11/6/25, an Independent Living Resident (identified as R1), contacted the facility's reception to request medical assistance. Upon arrival, staff noted bruising along R1's face, back, and arm. Per the report, R1 stated they had a series of falls throughout the week that they did not report, and the most recent being that morning. Staff noted additional bruising along R1's right rib cage. Emergency services were contacted and R1 was taken to the hospital where they were treated for multiple rib fractures. R1 was discharged 11/9/25 with medication changes for possible infection and given a walker. Per the report, R1's neuro and cognitive testing came back normal. During today's visit, LPA conducted interviews and file review. Additionally, LPA conducted a phone call with R1. Interviews corroborated that the facility responded immediately once notified of the incident and arranged for medical care. File review of R1's records note R1 to be independent in all Activities of Daily Living (ADLs). [Continued on LIC 809-C] [Continued on from LIC 809] 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.