Complaint·October 28, 2025

Page 3. side. Staff #1 then pulled the resident towards them and placed part of the diaper beneath the resident. Resident #1 then had to roll over to their left side to allow staff to pull the diaper through to the other side. This was normal practice when Resident #1 was changed. On 2/16/25, Resident #1 rolled over to the left and misjudged the size of the bed and ended up on the edge of the hospital bed. Resident #1 continued to slip off the bed before Staff #1 could prevent the fall. Resident #1 landed on their left side. As a result of the fall, Resident #1 had left side pain, arm pain, bruising and swelling and lay on the floor for about 30 minutes before staff were able to transfer the resident back to bed. The acute displaced fracture of the distal humeral shaft injury was not known until 2 days later. Per the investigation conducted by Investigator Padilla, there was insufficient evidence to support the allegation that due to neglect, lack of supervision, staff caused an injury to a resident. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided Page 2. into the home by Jossent Mckie, Staff. Rebeka Durgaryan, Administrator, was contacted via telephone by Ada Bozkurt, Staff and she arrived to conduct the visit at 11:59am. During the initial visit conducted on 2/25/25, LPA Yee conducted a tour of the facility and the resident rooms to observe the residents in care beginning at 11:14am, reviewed the food supply at 11:44am and did file review of all 5 resident files beginning at 11:50am. No formal interviews were conducted with staff or residents during the visit. Per tour of the facility on 2/25/25, no visually obvious concerns were observed with the facility. All 5 Residents were observed in their beds, either watching television, on a Zoom call for bible study and one resident in bedroom #3 was sleeping. Resident #1 was observed in bed wearing a hard splint on their entire left arm. Utilities were observed to be in use at the time of this visit. Food supply was inspected and there were sufficient perishable foods for a minimum of two days and non-perishable foods for a minimum of 7 days on site. There were 2 staff working during the visit. File review was conducted, and copies of resident files were requested. During the investigation conducted by Veronica Padilla, Investigator with Community Care Licensing Division’s Investigation Branch, she conducted interviews on 3/13/25 with Resident #1, Resident #2, Resident #3 and Resident #4. On 3/18/25, an interview was conducted with the Reporting Party. On 6/26/25 an interview was conducted with Staff #1, an interview with the Administrator and staff #2 on 7/1/25. Attempts to interview Staff #3 were unsuccessful. Also, as part of the investigation, facility files and documents such as medical records, hospice records and other extensive documents relevant to this complaint were obtained and reviewed. Regarding the allegation that staff caused an injury to a resident while in care, Resident #1, who is bed bound, was receiving incontinence care around 1745 hours(5:45pm) or 6:30pm on 2/16/25. Per interview with Staff #1 on the day of the fall, they started the diaper change while Resident #1 was laying on their right continued on LIC9099-C Page 2A ensure that there were no immediate concerns with the physical plant and residents. LPA Yee was let into the home by Jossent Mckie, Staff. Rebeka Durgaryan, Administrator, was contacted via telephone by Ada Bozkurt, Staff and she arrived to conduct the visit at 11:59am. During the initial visit conducted on 2/25/25, LPA Yee conducted a tour of the facility and the resident rooms to observe the residents in care beginning at 11:14am, reviewed the food supply at 11:44am and did file review of all 5 resident files beginning at 11:50am. No formal interviews were conducted with staff or residents on today's visit. Per tour of the facility on 2/25/25, no visually obvious concerns were observed with the facility. All 5 Residents were observed in their beds, either watching television, on a Zoom call for bible study and one resident in bedroom #3 was sleeping. Resident #1 was observed in bed wearing a hard splint on their entire left arm. Utilities were observed to be in use at the time of this visit. Food supply was inspected and there were sufficient perishable foods for a minimum of two days and non-perishable foods for a minimum of 7 days on site. There were 2 staff working during the visit. File review was conducted, and copies of resident files were requested. During the investigation conducted by Veronica Padilla, Investigator with Community Care Licensing Division’s Investigation Branch, she conducted interviews on 3/13/25 with Resident #1, Resident #2, Resident #3 and Resident #4. On 3/18/25, an interview was conducted with the Reporting Party. On 6/26/25 an interview was conducted with Staff #1, an interview with the Administrator and staff #2 on 7/1/25. Attempts to interview Staff #3 were unsuccessful. Also, as part of the investigation, facility files and documents such as medical records, hospice records and other extensive documents relevant to this complaint were obtained and reviewed. Regarding allegation #2 that Staff did not seek timely medical attention for resident, the investigation revealed that Resident #1 was receiving incontinent care on 2/16/25, around 1745 hours (5:45pm) or 6:30pm and had rolled over from their right side to their left side. Resident #1 misjudged the bed and had slipped onto the floor from the hospital bed. Resident #1 landed on their left side. Resident #1 experienced continued on LIC9099-C Page 3A. pain in the upper extremities and upper left arm with minimal movement. Swelling and bruising were noted on the forearm and elbow. Neither the Administrator nor staff called 9-1-1 to have the resident checked evaluated for any injuries. The resident was transferred back to bed after they spent about 30 minutes on the floor. Per interviews, staff stated that the resident refused medical services, despite the pain. Resident #1 receives hospice services for heart issues, and the Administrator called the hospice nurse on 2/17/25 to assess Resident #1 for the fall, despite the fall being unrelated to the resident’s hospice care plan. The hospice nurse suspected a fracture and scheduled an x-ray for 2/18/25. Upon evaluation, the nurse recommended that 9-1-1 be called, but the resident refused. The x-ray results revealed an acute displaced fracture of the distal humeral shaft. Again, the staff did not call 9-1-1 to obtain medical attention for Resident #1. Later that day, the resident had an in-person visit from the hospice doctor to discuss the results of the x-rays and treatment options were discussed. Hospitalization was recommended again and was refused by Resident #1. The potential consequences of the fracture was explained by the doctor and the resident still wanted to remain at the facility. On 2/21/25, almost a week after the fall, Resident #1 finally asked the administrator to be taken to the hospital. 9-1-1 was called to transport Resident #1 to the hospital. Per Investigator Padilla’s investigation, although the resident refused medical services, the resident signed an LIC627C – Consent for Emergency Medical Treatment Adult and Elderly Residential Facility, which was observed in the resident’s file. The Administrator should have exercised the authority granted to provide any necessary emergency medical care, regardless of the circumstances, to protect the resident’s wellbeing, but failed to do so. Resident #1 endured a total of 5 days of pain. Per the investigation, there is sufficient evidence to support the allegation that the staff did not seek timely medical attention for a resident, therefore the allegation is substantiated. Deficiencies are cited under California Code of Regulations, Title 22, Division 6, Chapter 8 Exit interview was conducted, Appeals Rights discussed and a copy was provided.