complaint·June 2, 2023

The complaint was accepted by Community Care Licensing Investigation Branch (CCIB) and it was assigned to IB investigator Christine Ferris. Investigator Ferris interviewed resident (R1), Administrator (S1), R1’s Power of attorney, Health and Wellness Director, two residents, private caregiver and R1’s primary physician. USC Verdugo Hills Hospital and Glendale Memorial Hospital medical records were obtained. The investigation revealed the following: “Resident sustained a fracture while in care”, based on interviews conducted, facility documents, and medical records obtained from USC Verdugo Hills Hospital and Glendale Memorial Hospital by investigator Ferris, the findings noted R1 had multiple falls from September 2020 to March 2022 which resulted in serious injuries including a fractured finger, a fractured arm, and a fractured neck and back. During the interview, R1 stated that all the injuries were accidental. The result of R1’s falls also happened during the evening when there was no 1:1 caregiver present. On September 2020, R1’s doctor had already recommended that R1 required one on one care and it would be neglectful if R1 does not have a one on one to use the bathroom, move and from the bed and wheelchair, or getting dressed. Although R1 had a private caregiver who works seven days a week from 10am to 5pm from December 2020 to April 2022. The facility also implemented safety checks every two hours, beginning and end of shift and gave a resident a pendant to call for help, however R1 misplaced the pendant. Facility failed to take any action after each incident involving a fall for R1 to mitigate the falls. Based on LPA’s interviews, and review of documentation regarding R1, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today, due to the facility failed to observe changes in resident’s health which resulted in resident sustained a fracture while in care. Refer to LIC 421IM*** At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(e) & (f) and may be assessed at a later date. An exit interview was conducted, and a copy of this report and appeal right were provided to the Wellness Director Anna Tupinyan along with the Appeals Rights.