Incident investigation·May 19, 2025

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management-Incident inspection regarding two self-reported Unusual Incident/Injury Reports (UIRs) received. LPA met with Executive Director Christian Castillo at 09:00 AM and explained the reason for the inspection. On 04/17/2025, Community Care Licensing (CCL) received a self-reported Unusual Incident/Injury Report (UIR) pertaining to an incident that allegedly occurred on 04/10/2025 regarding Resident #1 (R1). It was reported that on 04/10/25, R1 was noted to be sitting on the floor and R1 complained of hip pain. 911 was called and Paramedics transported R1 to Los Robles hospital for further evaluation. It was further reported that R1 had a fractured pelvis and was receiving treatment at Los Robles as of 04/15/25. On 04/30/25, CCL received a self-reported Unusual Incident/Injury Report (UIR) pertaining to an incident that allegedly occurred on 04/26/2025 regarding Resident #2 (R2). It was reported that on 04/26/25, R2 was noted to be lying on the ground in their bedroom, R2 had bleeding around their left ear. 911 was called ad paramedics transported R2 to Los Robles hospital for further evaluation. It was further reported that R2 was evaluated and admitted to the hospital for sustaining two (2) small subdermal brain bleeds. During today’s visit, the LPA conducted an interview with Executive Director Christian Castillo, four (4) staff, and obtained copies of pertinent information. No immediate health and safety concerns were observed during the visit. LPA will return at a later date if warranted. Exit interview conducted and copy of report provided.