Incident investigation·August 13, 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 09:30 AM and explained the reason for the inspection. On 07/25/2025, Community Care Licensing (CCL) received two self-reported Unsual Incident/Injury Reports (SIRs) pertaining to two incidents that allegedly occurred on 07/21/2025 and 07/23/2025 regarding Resident #1 (R1). It was reported that on both dates R1 was inebriated, sustained falls, 911 was called and Paramedics transported R1 to Los Robles hospital for further evaluation. On 07/29/2025, Licensing Program Analyst (LPA) Cortez spoke with the Director of Nursing, Gina Taylor, over the phone, and it was reported that R1 sustained a Left Rib fracture on the second fall. It was further reported that on 7/7/25, R1 was placed on hourly safety checks, and on 07/21/25 after their first fall a 1:1 was put in place as a safety precaution. 1:1 was in the room with R1, when R1 sustained the second fall on 07/23/25. During today’s visit, the LPA conducted an interview with Executive Director Christian Castillo, Director of Nursing Gina Taylor, four (4) staff, attempted to contact private 1:1, 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.