Incident investigation·December 23, 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 Memory Care Director Cristina Coronado. Executive Director (ED) Heather Myers arrived later during the visit. Community Care Licensing received an Incident Report on 12/22/25 in which it was reported that on 12/9/25, a Resident (identified as R1), fell out of their wheelchair due to uneven concrete when being assisted by a staff member down a ramp at the facility. Per the report, the resident hit their knees and head on the ground. Emergency services were contacted and resident was transported to the hospital where no injuries were found. Per the report, resident returned to the facility with no new orders. R1's responsible party and primary care physician were notified. During today's visit, LPA conducted interviews and file review. Additionally, LPA attempted to conduct a health and safety visit with R1, however R1 was being assisted by staff. LPA attempted again later during the visit, but R1 was attending lunch and LPA did not want to disturb their meal. Due to time constraints, LPA was unable to complete a determination regarding this case management visit, and additional visits may be necessary to complete review of this incident. 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 ED Myers to whom a copy of this report was provided. Their signature below confirms receipt of this document.