Facility Evaluation Report

06/04/2026 11:15 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Grace Hawkins. Today’s visit is regarding an incident that occurred on 01/19/2026 and was reported to licensing on 01/20/2026.

It was reported that on 01/19//2026 Resident 1 (R1) was sent to Oroville Hospital due to acting out of baseline. Resident was more confused than usual, unsteady on their feet and had bruising on their back and stomach. Resident was diagnosed with s/p likely mechanical fall, dementia, deconditioning. R1 returned from hospital on 01/20/2026.

During the course of the investigation, it was learned that R1 had an unwitnessed fall on 01/17/2026. EMS was called to assess R1. EMS notified POA and gave them the choice to transport R1 to hospital. Due to R1 not complaining of pain POA refused transport. When R1 fell on 01/19/2026 and was transported to hospital due to acting out of baseline, increased confusion and being unsteady on their feet. The bruising on R1s torso was discovered by staff on 01/17/2026, per the report of that incident.

After the initial fall on 01/17/2026 the facility increased checks for R1 to 15-minute checks. R1 has had no further falls or injuries.

No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to administrator Grace Hawkins.