Incident investigation·March 12, 2025

On 03/12/2025 at 10:30AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct a case management visit regarding the incident reports received on 03/11/2025. LPA met with Administrator, Kimberly Whittle and explained the purpose of visit. Based on the incident reports dated 03/06/2025 and 03/10/2025 revealed that resident (R1) had unwitnessed falls. R1 falls were caught on the camera in R1's bedroom supplied and used by R1’s family. On 03/03/2025, at approximately 10:00pm R1 fell after losing balance while getting items from dresser. On 03/10/2025, at approximately 3:00am, R1 had gotten up, R1's alarm pad had not sounded to notify a caregiver that R1 was up and in need of assistance and when R1 tried to put robe on and fell. During visit, LPA toured R1’s room, interviewed administrator and reviewed R1’s file. During the visit, LPA observed Camera with audio and video recording capabilities located in R1’s room. During interview, administrator stated camera was provided and installed by family. During file review LPA observed R1’s physician’s report didn’t indicate fall risk. Staff removed the camera during visit. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.