Incident investigation·April 7, 2026

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on a resident death reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director Kirsten Kearnaghan, as well as Residential Health Services Manager Alison Humora, who arrived later during the visit. Community Care Licensing received a Death Report on 4/1/26 in which it was reported that a resident (Identified as R1) had passed away on 3/28/26 at the hospital, following a fall at the facility two (2) days prior on 3/26/26. Per the report, R1 had an unwitnessed fall and was found by their private care aid who then notified the facility and requested aid. Per the report, R1 was experiencing hip pain and emergency services were contacted and R1 was transported to the hospital. R1 later passed away while at the hospital. During today's visit, LPA conducted file review and interviews, and provided consultation with Executive Director Kearnaghan. The facility is currently awaiting the death certificate and will forward to the Department once received. Per LPA file review and interviews, the facility responded appropriately by arranging for prompt medical attention for R1 upon notification of incident. Per review of R1's records, R1 was independent in ambulation and not indicated as a fall risk. At this time, LPA observed no immediate health and/or safety concerns and no deficiencies were cited during today's visit. Additional visits and follow-up may be necessary for complete review of this incident based on additional information from the Death Certificate once obtained. No Deficiencies were cited during today's visit. An exit interview was conducted with Executive Director Kearnaghan to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.