Incident investigation·July 28, 2025

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on a series of incidents reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Director of Resident Services (DRS) Coco Feng. Within a 2 week period (July 7th-21st, 2025), Community Care Licensing received four (4) incident reports regarding three (3) separate resident falls, with one (1) resident falling twice within that period. That resident, (identified as R1) had an unwitnessed fall on 7/7/25 in their unit, resulting in a head injury requiring staples. R1 had another unwitnessed fall in their unit two (2) weeks later on 7/21/25, but sustained no acute injuries, per the report. The next resident (identified as R2) had an unwitnessed fall in the dining area on 7/15/25, resulting in an upper extremity fracture. The final resident (identified as R3) had a fall in their unit on 7/17/25 and it was reported to staff by R3's spouse. Per the report, R3 refused emergency transport and was driven by their spouse to the hospital where a hand fracture was discovered. Emergency services were contacted for R1's and R2's falls, and responsible parties and Primary Care Physicians (PCPs) were notified for R1, R2, and R3. During today's visit, LPA conducted file review, a health and safety visit with R1 and R3, and provided consultation with DRS Feng. LPA was informed that R2 remains out of the community at this time. R1 is an identified fall risk and file review and interviews revealed implementation of actions taken to reduce/mitigate risk. Initial fall encounter for R2 and R3. No Deficiencies were cited during the visit. An exit interview was conducted with Director of Resident Services Feng to whom a copy of this report was provided. Their signature below confirms receipt of this document.