complaint·August 1, 2025

Five (5) out of five (5) residents interviewed feel safe at the facility. The Executive Director, Assistant Administrator, four (4) out of four (4) staff interviewed denied the allegations stating that the facility’s policy regarding falls is contacting 9-1-1 if the resident has a unwitnessed fall or has Dementia. However, based on record review, facility’s Fall Policy states that if the resident is severely hurt or severe pain, call 9-1-1. Based on record review, Special Incident Report dated 7/27/2025, 7/20/2025, and 7/13/2025, the facility called 9-1-1 due to a fall. These SIRs were missing the facility care staff conduct an assessment checking for visible injuries or severity of pain prior to contacting 9-1-1. The residents had no injuries noted. Based on record review, staff’s most recent documented in-service on fall prevention was conducted on 03/26/2025. However, based on staff interview, the Assistant Administrator and one (1) of the staff interviewed admitted that there was a recent staff in-service held on 07/26/2025, regarding an updated Fall Policy that indicates the facility hiring a Licensed Vocational Nurse that would help determine if the resident’s fall is a medical emergency in which the facility was unable to provide documentation of that in-service. Therefore, there was sufficient supportive evidence to concur with the reported allegation. Based on LPA's interviews conducted with the residents and staff, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 1 are being cited on the attached LIC 9099D. An exit interview was held with the Executive Director, Pamela Ogot, and a copy of this report and appeal rights were provided.