Facility Evaluation Report

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility for the purpose of delivering finding regarding case management conducted on March 07, 2025. LPA Haddadin was greeted by Assistant Executive Director, Sammy Lee who granted access to the facility, at which time the purpose of the visit was explained. On March 03, 2025, the Regional Office received a self-reported unusual incident report from the facility reporting the hospitalization of Resident 1 (R1) resulting in a bone fracture. A case management health and safety visit was then completed on March, 07 th , 2025. The investigation determined as follows:

A review of facility and medical records established that Resident 1 (R1) has a documented history of Parkinson’s Disease with progressive physical decline, intermittent confusion, and Mild Cognitive Impairment, as reflected in a Physician’s Report dated May 10, 2022. Internal Incident Reports from October of 2024 to February 12, 2025, show that R1 experienced at least eight unwitnessed falls despite existing fall-risk measures developed by the Assisted Living Waiver Program (ALW). A review of R1's Individual Service Plan assessed by the dated February 6, 2025, to August 6, 2025, R1 was identified as having poor safety awareness and being at high risk for falls. A fall mitigation plan had been developed by the ALW and recommended to manage these risks. {***CONTINUE 809C***}