complaint·April 29, 2026

On 01/27/26, LPA interviewed Staff #12 (S12). On 03/23/26, LPA received the second-floor facility sketch. On 04/29/26, LPA interviewed attempted to interview ten residents in memory care but they were unable to coherently answer the questions. Investigation revealed the following: Regarding the allegation, “Due to staff neglect, resident sustained injuries,” it is alleged Resident #1’s (R1) fall resulted in lacerations all over R1’s body. Record review of R1’s Hospital Physical Therapy OPIB Plan of Care revealed R1 fell (04/08/25) prior to admission and sustained a fracture on part of the hip joint. R1 was non-weightbearing for six weeks. Record review of R1’s Physician’s Report (04/21/25) revealed R1 is non weight bearing on right lower extremity and needs assistance with toileting needs. Review of Service Plan (06/01/25) revealed R1 was dependent on staff members for all mobility/ambulation needs, required hands on assistance by staff members, able to hold weight for few steps with one-person assist but then becomes weak. R1 was a fall risk and needed to be monitored and assisted as needed for safety. R1 requires routine toileting program. Review of Incident Report (Occurred 07/04/25) indicated that R1 had an unwitnessed fall in R1’s room that resulted in skin tears on both hands, an abrasion on the left knee, and noted hypotension. R1 was transferred to the hospital for further evaluation. Review of Hospital Record (ED Provider Note, 07/04/25) revealed R1’s open right finger wound (laceration with tendon exposed) was repaired using local anesthesia and suturing. R1 was given intravenous antibiotics to prevent infection of the open wound. Interview with Staff #1 (S1) indicated R1 had dinner, watched television in the common area, and then went to R1’s bathroom. S1 indicated R1 was toileting and had an unwitnessed fall. R1 was found on the floor with the walker in front of R1. S1 indicated staff does assist R1 but if R1 goes there [bathroom], R1 will toilet independently. Two out of three caregivers (S10 – S12) working on the second floor at that time indicated they did not assist R1 to the bathroom. The third caregiver could not recall R1's incident nor working that day. Regarding the allegation, “Due to staff neglect, resident sustained injuries” based on record reviews and interviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Civil penalties are being assessed, see LIC421IM. At this time, an additional civil penalty determination is pending in reference to Health & Safety Code 1569.49(f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident. An exit interview was conducted, plans of correction were developed and appeal rights provided on 04/07/26 and a copy this report was left with Administrator Lourdes Menchaca.