Facility Evaluation Report

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Case Management Visit to follow up on a Special Incident Report (SIR) faxed to the Department on 4/11/25. LPA met with Vincent Gonzaga and explained the reason for the visit.

The Department received an SIR dated 4/11/2025 indicating the following: On 4/10/25 R1 was hospitalized after experiencing an unwitnessed fall, this fall caused resident to sustain a hematoma to the forehead, left wrist, friction burns and fracture.

LPA obtained copies of the following documents: R1's FACE Sheet, Appraisal Needs & Services Plan/IPP, Physician's Report, Medication List, and discharge paperwork from hospitalization dated 4/10/25.

LPA toured R1's bedroom and activity room. No concerns, obstructions, or anything out of the ordinary was witnessed

No deficiencies observed during today's visit.

Exit interview held and a copy of the report was provided to Administrator Vincent Gonzaga.