Follow-up on corrections·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 12/8/25, a Resident (identified as R1), was noticed not to be present by a caregiver around 11:30am. Per the report, multiple staff then searched the facility to find R1, who was found to have fallen down a stairwell with their wheelchair on top of them. R1 was noted to be awake and alert and staff contacted emergency services who then transported R1 to the hospital where they were treated for a large hematoma to their glute area. R1 returned to the facility 12/11/25 with orders for new medications. During today's visit, LPA conducted interviews and file review. Additionally, LPA conducted a health and safety visit with R1. Per staff interviews, a fire alarm had gone off during lunch (from 11am-12pm) and staff began conducting room checks after it had been determined to be a false alarm from the kitchen. Staff interviews corroborated that R1 must've panicked or gotten confused from the alarm and tried to self-evacuate from their room before staff got to them. The stairwell R1 fell in is immediately next to R1's room. Interview with the staff member who first noted R1 to be missing from their room stated that they had assisted R1 with bathing earlier and that R1 was seated in their recliner watching television when the staff member left to assist the next resident with their shower. [Continued on LIC 809-C] [Continued from LIC 809] All staff interviews corroborated that R1 is a fall risk and required assistance when ambulating with their walker or wheelchair. File review of R1's physician's report (dated September 2023) revealed that R1 has a diagnosis of Dementia and utilizes a walker due to motor impairment. Per review of R1's assessment dated June 2025, R1 is noted to ambulate independently with or without an assistive device and noted to be a fall concern. However, per R1's service plan dated December 2023, R1 requires total assist with ambulation. It is noted that R1 is able to ambulate with the assistance of a walker but that an escort will be provided for safety. R1's full service plan was not updated until December 2025, after this incident. Per review of the new service plan, R1 remains a total assist for ambulation and that R1 will be escorted to meals and activities. Goals and interventions to reduce R1's fall risk now include additional reminders to utilize their pendant for assistance and for staff to provide reminders for R1 to utilize their assistive device if observed trying to ambulate without it. Per interview with administrative staff, the facility has also implemented higher frequency checks on R1 (hourly). The facility responded accordingly by conducting room checks after a fire safety event and conducting a search once R1 was noted to be unaccounted for and then arranging for prompt medical attention once found. However, one (1) Type B deficiency is being cited today as the facility failed to submit a written report of the incident to the Department within seven (7) days. Date of incident was 12/8/25, date of report submission was 12/21/25. Details of the deficiency are noted on the attached LIC 809-D along with Plan of Correction (POC). One deficiency was cited during today's visit. An exit interview was conducted with Executive Director Myers to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.