Incident investigation·January 6, 2026

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management - incident visit and met with Executive Director (ED) Marife Duewel. On 01/02/2025, the Department received a notice that resident R1 had a fall and was sent to hospital on 12/31/2025 and R1 had a fall on 12/202025. The Department interviewed R1's family member (FM). FM stated that he/she does not find the facility staff had fault for the incident on 12/31/2025 and stated the facility provides good care to R1. FM confirmed R1 had a fall on 12/20/2025. LPA requested R1's physician report and appraisal needs and service plan. LPA interviewed ED. ED stated on 12/20/2025,around 6:30AM after R1's morning care, R1 had a fall at memory care unit hallway. ED stated staff found R1 was on the floor and called 911 immediately. R1 was sent to hospital. ED stated on 12/31/2025, around 12:30AM, staff saw R1 was walking at the memory care unit hallway. Staff S1 saw R1 was falling and tried to help but was unable to stop R1's falling. S1 called Med Tech (S2). S2 came on site and assessed R1 and called 911 immediately. R1 was sent to hospital. ED stated R1 still at hospital today. Continue on LIC809-C. Oage 1 of 2. LPA interviewed Wellness Director (WD). WD stated resident R1 had fall on 12/20/2025 and 12/31/2025. WD stated staff found R1 was on the floor on 12/20/2025 and 12/31/2025 and called 911 immediately. The facility did not send incident report for R1's fall and was sent to hospital on 12/20/2025 to CCL office. Based on the review of R1's appraisal/needs and service plan, the facility did not update R1's care plan after R1's fall on 12/2025. Deficiencies were noted for today's visit, please see LIC809-D. Exit interview was conducted with ED. The report was provided to ED for reveiw. A copy of the report was provided to ED.