Facility Evaluation Report

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management visit to follow up on a resident death reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Ada Navarrete, Director of Health Services.

Community Care Licensing received a Death Report on 4/22/26 in which it was reported that a resident (Identified as R1) had passed away on 4/19/26 following an unwitnessed fall and being sent out to the hospital. Per the report, R1 was found by the side of their bed with their nose bleeding and a hand laceration and complaint of pain. Emergency personnel was called due to head trauma and hospice was notified by facility staff. R1 was transported to the hospital where R1 later passed away with a diagnosis of closed wedge compression fracture of T4 and T7 Vertebrae .

During today's visit, LPA conducted file review and interviews, and provided consultation with Navarrete, Director of Health Services. Per review of R1's records, R1 was able to come and go from the facility unsupervised.

At this time, LPA observed no immediate health and/or safety concerns and no deficiencies were cited during today's visit. Additional visits and follow-up may be necessary for complete review of this incident based on additional information from the Death Certificate once obtained. An exit interview was conducted with Ada Navarrete, Director of Health Services to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.