Incident investigation·March 12, 2025

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management Incident inspection at the facility today. The LPA met with Administrator Joeyvic Alvarado and explained the reason for the inspection. On 02/27/2025, Community Care Licensing (CCL) received an Unusual Incident/Injury Report (LIC 624) pertaining to Resident #1 (R1). Please note report was submitted after hours and LPA did not receive until 02/28/2025. The report stated that on 02/25/2025, while walking on the beach with several residents, R1 lost their balance and fell. R1 was transferred to the hospital for immediate medical treatment. Furthermore, R1 returned to the community on 02/26/2025 with a back fracture. On 02/28/2025, the LPA spoke with Administrator Joey Alvarado regarding the incident. She stated R1 was out on an outing to the beach with other residents and staff, they were walking the board walk and after the fall R1 was sent to the hospital and was diagnosed with a back fracture. The Administrator stated when Staff 1 (S1) was interviewed they conveyed that they were walking holding R1, and another resident (R2) by hands and when a third resident (R3) walked passed them, R2 let go of S1's hand to follow R3. S1 let go of R1 in an attempt to go after R2 and R1 fell. The Administrator stated R1 uses a walker, however S1 did not take R1's walker to the outing as they felt confident that they were going to be able to hold on to them and S1 received a corrective action. During today's inspection, the LPA conducted file review for R1 and S1 beginning at 1:28 PM. File review revealed that per R1's Resident Appraisal (LIC603A) dated 09/24/24, R1 has balance issues, ambulatory with assistance, needs assistance in walking, and is not able to walk without any physical assistance (e.g., walker, crutches, other person), or not able to walk with a cane. Per R1's Physician Report (LIC602) dated 09/24/24, R1 has a history of mechanical fall. Furthermore, R1's file review also revealed that R1 uses a walker and is a high fall risk. Report will continue on LIC809-C, 2nd page. File review revealed that on 02/28/2025, S1 received a corrective action notice for allowing residents to get off the bus to walk on the sand during a scenic drive to the beach, and one of those residents was taken off the bus without their assistive device which caused them to fall. Furthermore, S1 received a safety in-service training on 02/28/2025. Based on the information obtained, there is sufficient evidence to support a deficiency is warranted as R1 sustained an injury as a result of S1 taking R1 on an outing to the beach without their assistive device. The following deficiency was cited (See LIC 809-D) from CA Code of Regulations, Title 22, Division 8. Failure to correct the deficiencies may result in civil penalties. An immediate civil penalty of $500 was issued. Exit interview conducted. A copy of the report and appeal rights were provided.