Incident investigation·May 28, 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 Caregiver Christine Coleman. Administrator Marilyn Ancho arrived later during the visit. Community Care Licensing received an Incident Report on 4/3/25 in which it was reported that Resident #1 (R1) had a fall during the night. Per the report, R1 denied multiple offers by staff to be sent out for evaluation and requested their Responsible Party (RP) to be called instead. R1's RP arrived in the morning to assist with a tele-health visit for R1, and R1 began expressing pain. RP contacted emergency services and they arrived to assist R1 into RP's car. R1 was evaluated at the hospital was determined to have multiple rib fractures sustained from their fall. During today's visit, LPA conducted file review, a health and safety visit with R1, and provided consultation with Administrator Ancho. File review and Interviews reveal R1 was not previously determined to be a fall risk nor did R1 display a change in condition immediately following their incident. Additionally, Administrator Ancho informed LPA of implemented measures to aid in R1's care and supervision moving forward, including fall monitors and increased frequency of checks. No deficiencies were cited during the visit. An exit interview was conducted with Administrator Ancho to whom a copy of this report was provided. Their signature below confirms receipt of this document.