complaint·November 1, 2023

hemorrhage. On 9/13/22 and 9/23/22, IB conducted interviews with R1’s responsible party, who confirmed that R1’s falls were unwitnessed and information from facility administrator regarding the falls were not forthcoming. On 9/23/22, IB received additional information that R1 experienced another fall on 6/23/22, sustaining fractures at the left clavicle and left rib, displaced with no healing present. On 10/20/22, IB conducted interviews with the facility administrator and staff, who confirmed that R1 was observed with blood coming from the ear on the morning of 7/24/22. They confirmed that R1 was transported to the hospital, where R1 was diagnosed with a skull fracture and subdural hematoma. Staff stated they did not witness R1’s fall or other traumatic events. Staff did admit to having trouble providing care for R1 due to R1’s progressing condition. Although R1s falls were confirmed unwitnessed, the information that IB obtained reveal that R1 had a behavior that was progressing for the last few months. Furthermore, it was revealed that the facility did not implement sufficient fall preventive measures, after R1 experienced another significant injury from a fall prior, that happened on 6/23/22. The licensee was unable to provide the necessary care and supervision to meet R1’s needs. Therefore, based on the information obtained, the allegation of resident suffering fractures and injuries from falls due to inadequate care and supervision is Substantiated. Citations issued on the 9099D. An Immediate Civil Penalties will be issued today, in the amount of $500.00. At this time, the administrator, Francis Martir is out on leave. LPA spoke with her back up administrator, Michael Custodio over the telephone and informed him that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f).“Appeal Rights discussed . Exit interview held. A copy of the LIC9099, LIC9099C, LIC9099D and LIC421IM (Civil Penalty Assessment), and Appeal Rights were provided to the house manager, James Olaolia who is present during this visit.