Incident investigation·September 8, 2025

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management visit to follow-up on an incident reported to Community Care Licensing. LPA met with Business Office Manager Vicky Mammo and discussed the purpose of the visit. Community Care Licensing received a LIC624 Unusual Incident/Injury Report in which it was reported that Resident #1s (R1) had a witnessed fall that resulted in a serious injury. According to the report on August 31, 2025, R1 was being assisted in toileting when R1 lost balance and fell while using an arm rest walker. R1 records revealed R1 only requires standby assistance and cuing. Interviews and records revealed R1 received immediate medical care after the fall. During today's visit, LPA conducted a health and safety check of the residents in care and provided consultation. No deficiencies were cited during today’s visit. An exit interview was conducted with Business Office Manager Vicky Mammo and LVN Cristina Senescalli. The Licensee was provided a copy of their appeal rights (LIC9058 03/22), and this report.