Complaint·July 22, 2025

On 07/22/25, Licensing Program Analyst (LPA) Yang arrived unannounced to deliver complaint findings on the above allegation. LPA introduced self, stated the purpose visit, and met with Administrator Mike Chapman and Director Resident Services Mandy House. During the course of the investigation, the Department conducted interviews and reviewed records and based on review, the preponderance of evidence standard has been met, therefore the allegation alleging staff did not seek timely medical attention for resident’s fracture which resulted from an unwitnessed fall is SUBSTANTIATED. Based on records reviewed and interviews conducted, R1 had an unwitnessed fall and sustained fracture. R1 was taken to Urgent Care on 5/5/25 and returned to the facility. From 5/5/25 to 5/8/25, R1 complained of pain as documented on the facility’s progress report. No medical attention was sought until staff called emergency services on 5/13/25. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D. The issuance of additional civil penalties is pending and currently under review. The details of additional civil penalties will be outlined in a future report to the facility, if any. Exit Interview conducted. Appeal Rights provided.