complaint·November 5, 2025

Pg 2 On 3/25/2024, R1, a known fall risk according to care plan dated 10/13/2023, had a fall in their room while attempting to change into their pajamas. S1 reported hearing R1 call for help and found them on the floor near their bed. S1 stated, “R1 said they lost their balance and fell. I usually remind them to press the pendant, but I didn’t see them before they fell.” S3 and S4 responded to the radio call and assisted R1. S4 reported that R1 said, “It hurts. It hurts. I fell,” and also, “Get me off this floor.” S1 and S4 helped R1 into a recliner, after which S4 called 911. Medical records obtained confirmed that R1 sustained a left hip fracture requiring surgical intervention. W1 expressed dissatisfaction with staff supervision and stated, “R1 had told me before that no one checked on them as much as they should. This isn’t the first time R1 has fallen, and it shouldn’t have happened.” R1 experienced multiple falls before 3/25/2024, including incidents on 8/7/2019, 1/1/2020, 1/15/2021, 6/11/2022 and 9/1/2023. Despite these incidents, the facility failed to revise R1’s care plan or implement additional safety measures. S1 stated, “I usually remind them to press the pendant.” S1 also reported that R1 would place their walker by the door, and that they typically checked on R1 four times per shift. S2 stated that R1 required help with showers, dressing, toileting, blood sugar checks, and escort assistance. S2 added, “R1 was changing into their pajamas when they fell and did not press their pendant for help.” Report Continues on LIC9099-C Pg. 3 S3 confirmed that residents at risk of falling are required to be checked every 30 minutes, minimize environmental clutter, and use call pendant for assistance. S3 noted, “The facility does not have any real fall prevention methods in place for residents.” S3 added, “R1 began losing their balance but refused staff’s help. They had a walker but refused to use it and held onto rails in the facility for balance.” S4 reported that staff check call pendants monthly for functionality and all residents are expected to wear them 24/7. S4 stated, “The facility does not have other fall prevention equipment such as fall mats as not a lot of residents are considered a fall risk.” Interviews revealed that R1’s pendant was often left on their nightstand rather than worn or kept within reach. Incident reports for R1’s prior falls, including the fall on 1/15/2021, without follow-up details or documentation of corrective actions. Facility records provided did not show that R1s previous falls resulted in a reassessment of R1’s care needs or adjustment to their supervision. Staff, including S1 and S3, noted that R1 had become increasingly withdrawn in the month prior to the incident. S1 shared, “In the last month or so before R1 left the facility, they became very withdrawn, sad, and cried all the time. R1 told me that their son was sick.” However, there was no evidence of additional emotional support being provided, nor documentation of care planning to address R1’s reduced help-seeking behavior. Records and interviews overall did not have proactive, consistent strategies to mitigate R1’s known fall risk despite repeated incidents and observed decline. ****An immediate civil penalty of $500 is being assessed on today’s date. Civil penalty determination related to serious bodily injury is pending. **** Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are 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 with Executive Director. A copy of this report and appeal rights was provided. Pg. 2 On the allegation “Staff did not ensure reporting requirements were followed.” The fall involving R1 on 3/25/2024 was reported via LIC 624 to Community Care Licensing and documented in the facility’s records. Staff interviews confirmed that after the incident, notifications were made to R1’s physician, responsible party, and emergency services in accordance with regulatory requirements. Specifically, records show that R1’s physician was notified via facsimile at 20:00 hours, and their POA was contacted via telephone at 16:20 hours. Although the reporting party stated they were initially told that the incident had been reported to Licensing when it had not, the Department verified that a report was submitted by the facility within the appropriate timeframe. On the allegation “Staff did not ensure resident room was free from obstruction” The Department reviewed photographs of R1’s room submitted by W1 and conducted a review of the facility’s safety practices regarding environmental hazards. While W1 expressed concern regarding clutter in R1’s unit, staff interviews revealed that fall prevention strategies included reminders to reduce clutter and arrange furniture to allow for safe walkways. The Personal Service Plan dated 10/13/2023 stated, "Encourage R1 on reducing environmental clutter and arrange furniture for adequate walkways." Interviews with staff who responded to the fall did not indicate that obstructions or clutter directly caused or contributed to the incident on 3/25/2024. S3 stated that R1 was found close to their bed, and S4 confirmed that R1’s room did not appear to be cluttered during the response. Based on observations, photographs, interviews and file review the allegations above are unsubstantiated . Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted and copy of report provided.