Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management visit to follow up on five self-incident report and one death report dated between 8/25/25 & 9/5/25 received by the department regarding falls in assisted living unit and met with Patricia Gustin, Administrator.

Death report received on 8/27/25 indicates that on 8/25/25 the facility was notified by an outside party that resident (R1) passed away on 8/25/25 while in the hospital. Previously, on 8/12/25 the department received a self-incident report notifying CCL about R1's hospitalization on 8/7/25 due to altered mental status and weakness. During today's visit, LPA requested death certificate because R1 was not receiving hospice services at the time of their passing. According to death report, R1 had a diagnosis of cirrhosis of the liver, kidney failure and hypertensive heart disease.

-On 8/29/25, incident received dated 8/20/25 resident (R2) called for assistance due to a fall after returning from the hospital, staff called 911 to transport R2 back to the hospital for increased falls and change of condition, responsible parties were notified. Today, LPA learned that R2 was transferred to a rehabilitation facility for treatment and there is no date for them to return to the facility.

-On 8/29/25, incident dated 8/27/25 reported that resident (R3) was observed by med-technician while passing their medications that R3 was lying on the floor in a prone position with their walker positioned on their back.