complaint·January 20, 2022

Investigations Branch (IB) Investigator Edward Hector conducted staff interviews on 2/14/20, 2/18/20, and 3/5/20. Staff interviews revealed that staff was present before and after the incident, but not at the time of the fall. Staff admitted to leaving R1 alone while assisting another resident. According to medical records, the fall resulted in a hip fracture. Incident reports submitted to the Woodland Hills North Regional Office confirmed the occurrence of a fall resulting in hip fracture. According to information obtained from staff interviews, file review, and incident report review, there is sufficient information to support the allegation that the resident sustained a hip fracture due to a lack of care and supervision. Therefore, this allegation is substantiated. A $500 immediate civil penalty is assessed today for a violation resulting in injury to R1. The licensee/administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Exit interview conducted. Appeal rights given. A copy of the report was issued.