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) Denise Notter. Community Care Licensing received an Incident Report on 11/26/25 in which it was reported that on 11/22/25, Resident #1 (R1), had displayed a change in condition. Responding staff had called emergency services and R1 was taken to the hospital where a closed head injury was discovered, however the injury was unable to be categorized as new or old. The report notes that per R1's responsible party, R1 had a history of this type of diagnosis. Resident returned to the facility next day with no new orders. The report notes that three (3) hours before, R1 was found to be sitting on the floor on a landing mat, which alerted staff. R1 was noted to be alert and verbally responsive, and denied any pain. During today's visit, LPA conducted interviews and file review. A health and safety visit with R1 could not be completed as R1 had passed away shortly after the incident from their hospice diagnosis. Per file review and interviews, R1 was a high fall risk and their needs & services plan highlighted various measures in place to mitigate risk. At this time, LPA observed no health and/or safety concerns and no deficiencies were cited during today's visit. An exit interview was conducted with Executive Director Notter to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.