Incident investigation·November 12, 2025

Licensing Program Analyst (LPA) Amy Rodgers 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 Administrator Elizabeth Gastelum and Licensee Debra Bunnell. Community Care Licensing received an incident report on 11/10/2025 regarding an unwitnessed fall involving Resident #1 (R1). According to the report, the fall occurred when R1 attempted to transfer themselves out of bed without assistance, immediately after using the call button. R1 informed staff that they were not experiencing any pain or discomfort. The facility reported that no bruising was observed at the time of the incident. However, during staff interviews, it was noted that bruising had been observed on 11/09/2025. Staff also stated that on the date of the incident, R1 was cognitively aware and ate dinner at the dining table. Facility notified Hospice as well as responsibly party. According to department interviews with the Hospice agency they evaluated R1 on 11/7/2025 and found no injuries or bruising. During today's visit, LPA conducted interviews and provided consultation with Administrator and Licensee. A health and safety visit was completed at the time of the visit with all Residents including R1. No Deficiencies were cited during the visit. An exit interview was conducted with Administrator Elizabeth Gastelum to whom a copy of this report was provided. Their signature below confirms receipt of this document.