complaint·May 22, 2025

***CONTINUES FROM 9099*** The department interviewed staff who stated they were aware that R1 was a fall risk but were never given any instructions from management to change the level of care they were providing to R1. Staff stated that they performed random checks on R1 every hour or two hours at most or more frequent whenever they got the chance but there was no formal monitoring plan in place. The only measures taken were that R1’s bed was lowered, and a fall mat was placed on the floor beside the bed. Multiple interviews with S1 revealed that fall preventative measures did not change and were the same beginning after R1’s first fall to the last fall incident. Based on the department’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted, a copy of this report and appeal rights provided.