complaint·February 11, 2026

. . . Continued from LIC 9099-C1 The complaint alleges Resident R1’s death was questionable. On 01/01/2023, R1 sustained a fall and was transported to the hospital. Medical records indicate that, upon admission, R1 was diagnosed with a closed fracture of the right hip. On 01/02/2023, R1 was transferred to another hospital with the same admission diagnosis. On 01/03/2023, R1 underwent surgical repair of the right hip fracture. On 01/08/2023, R1 was discharged to hospice for comfort care due to poor quality of life and inability to participate in life-sustaining therapies. On 01/15/2023, R1 was discharged from hospice following death at the hospital on 01/14/2023. Final active problems included a closed fracture of the right hip and many other health conditions. R1 did not return to Elder Ashram after his fall on 01/01/2023 R1’s death certificate lists the immediate cause of death as acute hypoxia respiratory failure, with the time between its onset and R1’s death listed as days. There were two underlying causes listed: pneumonia and sepsis, both with the time interval between onset and death listed as days. According to interviews, review of facility records, and a review of R1’s medical records, there was not enough information to state that R1’s death was questionable, nor that facility staff were at cause. The data analyzed does not support this allegation. The complaint alleges that lack of supervision from staff resulted in Resident R1 falling and thereby sustaining a fracture while in care. Prior to R1’s admission to the facility, the resident appraisal of 12/03/2022 noted that R1 “is a big fall risk so needs to be helped and watched”. R1 was admitted to the facility on 12/05/2022. On 12/10/2022, 12/16/2022, 12/21/2022, and 01/01/2023, R1 sustained falls. R1 was transported to the hospital emergency department (ED) after each fall. R1 sustained a laceration on his chin and injuries to his forehead on 12/16/2022 and 12/21/2022. 12/16/2022 hospital discharge instructions state, “frequent falls and instability are likely due to dementia and dehydration / deconditioning.” On 12/21/2022, R1 was transported to the ED by his son W2. On 01/01/2023, R1’s fall resulted in a closed fracture of the right hip. On 12/10/2022 and 12/16/2022, facility staff submitted Physician’s Fax Reports to R1’s physician. Facility did not receive a reply to the 12/10/2022 fax with new orders. On 12/16/2022, R1’s physician replied and stated, “Have upcoming appointment with him this week. No new recommendations now.” Continued on LIC 9099-C3 . . . Continued from LIC 9099-C2 On 12/16/2022, according to reviewed email correspondence, facility staff communicated concerns to W2 regarding R1’s high fall risk, frequent falls, medication concerns, current level of care, and the need for reassessment for a higher level of care, as well as the need to schedule a care conference. On the same date, a second email was sent to W2 indicating that R1’s one-on-one supervision was extended due to R1’s increased ambulation that resulted in his continued falls. On 12/21/2022, W2 emailed facility staff regarding a medication prescribed by R1’s physician and advised that the medication could increase R1’s risk of falling. Facility staff subsequently expressed concern that the medication could further elevate R1’s fall risk. According to interviews, review of facility records, and a review of R1’s medical records, there was no indication that lack of supervision from staff resulted in Resident R1 falling and thereby sustaining a fracture while in care. The data analyzed does not support this allegation. The complaint alleges that R1 had unexplained weight loss of 20 lbs. R1’s weight in his Physician’s Report dated 10/27/2022 is 138 lbs. It was 39 days between the Physician’s Report and the date R1 was admitted into Elder Ashram on 12/5/2022. There is no record of R1’s weight upon admission nor during the 27 days R1 lived at Elder Ashram. Upon admission into the hospital on 1/1/2023, R1’s weight was recorded as 124 lbs. and 9 oz. That was a loss of 13 lbs. and 3 oz. R1 lived at Elder Ashram fewer days than the number of days between the Physician’s Report and his admission into the hospital on 1/1/2023. The data analyzed does not support this allegation. The complaint alleges that facility staff failed to assist R1 with grooming. The AED stated that the staff worked as a team to groom R1, because he was physically aggressive. They used different strategies for approaching him and for working with him. If he was not okay with one staff member at one time, then another staff member would come a little later. He hit and punched staff when they assisted him during grooming. Nonetheless, they kept his body and his clothes clean. The data analyzed does not support this allegation. Continued on LIC 9099-C4 . . . Continued from LIC 9099-C3 The complaint alleges that the facility did not have enough staff to properly care for the residents. Four staff members were interviewed at Elder Ashram about possible understaffing during December 2022 and January 2023. The AED stated that during the time R1 was at the facility, between December 2022 and January 2023, the shift coverage and resident population remained the same. She also stated that Elder Ashram has never had issues with understaffing. Staff member S1, a Licensed Vocational Nurse, stated that the facility is understaffed “sometimes,” but it is only from shift to shift and never for an extended amount of time. Staff member S2, a Care Partner, stated that there has never been an understaffing issue. Executive Director (ED) Maria Lourdes Riera stated that the facility has never been understaffed for an extended period. A review of complaints concerning understaffing at this facility supported these statements, because none were substantiated. The data analyzed does not support this allegation. The complaint alleges that the facility did not report resident fall incidents, hospitalization, and death to Community Care Licensing (CCL). A review of the records shows that the facility did make the required reports to CCL. The data analyzed does not support this allegation. Although the allegations may have happened, or were valid, there is not a preponderance of evidence to prove them; therefore, the allegations are UNSUBSTANTIATED . Exit interview conducted and a copy of this report was provided.