Facility Evaluation Report

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr made an unannounced case management visit in conjunction with Unusual Incident/Injury Report (UIIR) dated May 26, 2026. LPA was greeted and granted entry by Executive Director (ED) Kathleen Olson. LPA explained the reason for the visit.

Per UIIR, on May 24, 2026, resident 1 (R1) was getting up, lost his balance and fell backwards. Per UIIR, R1 was admitted to the Hospital for multiple back fractures. Per UIIR, the Neurosurgeon recommended surgery for R1.

During today's visit LPA reviewed the Death Report dated June 4, 2026, for R1. Per Death Report, on May 30, 2026, R1 passed away at the Hospital.

A Health and Safety inspection was conducted, and LPA Ramirez observed no Health and Safety concerns during today's visit.

Based on observations and records reviewed during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with ED Olson and a copy of this report were provided at the time of exit.