Incident investigation·September 17, 2025

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of following up on a self-reported incident that occurred on 09/10/2025. Upon arrival, LPA was greeted by facility staff. Administrator was contacted via telephone and arrived at 10:20AM. Entrance interview conducted On 09/12/2025, an Unusual Incident/Injury Report was received at the Woodland Hills North Regional Office related to Resident #1 (R1). Written report indicates that on 09/10/2025 during the dinner hour, R1 had been seated at the dining table. Staff had left the area to assist other residents when R1 stood up unassisted, resulting in a fall. R1 was sent to the hospital, where it was determined R1 had sustained a fracture as a result of their fall. Additionally, R1 had a sepsis infection and passed away on 09/11/2025 while hospitalized. During today's visit, LPA interviewed Administrator related to the incident and LPA, along with Administrator, toured the pertinent areas of the facility at 11:08AM. No immediate health and safety hazards were identified during today’s visit. LPA also reviewed R1's file and obtained copies of pertinent documents . A copy of R1's death certificate was not available at the time of the visit. LPA may return at a later date if further investigation is warranted. No citations issued. Exit interview conducted. A copy of today's report was provided.