Incident investigation·May 1, 2025

On 05/01/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Case Management Visit to the facility listed above. LPA met with Administrator, Joe Saldana, and the purpose of the visit was explained. LPA was granted entry into the facility. LPA conducted a Case Management Visit to follow up on a Special Incident Report (SIR), submitted on 04/18/2025 and a Death Report submitted on 04/24/2025 for Resident R1. LPA received an incident report on 04/18/25, informing the department R1 had a witnessed fall on 04/12/25. R1 was transferred to Kaiser Harbor City Emergency Room for further evaluation and treatment due to hitting their head. LPA received a Death Report on 04/24/25 for R1 who passed on 04/22/25 while at Kaiser Harbor City Hospital. On the Death Report it was indicated under the Cause of Death that R1 was transferred on 04/12/24 due to a fall. Under the section Conditions Prior to or Contributing to Death, R1 had a hip surgery. During today’s visit, LPA inspected the fourth (4 th ) floor, checked all hallways, walkways, common rooms, and resident R1’s room. LPA observed all walkways and hallways to be clean, clear, and free of obstructions and hazards. All common rooms and Resident R1’s room was observed clean, clear, and free of hazards. All rooms were observed with ample lighting. Additionally, during today’s visit, LPA interviewed Staff S1-S4, received, and reviewed documents pertinent to visit. LPA received and reviewed the following documents Staff Roster, Resident Roster, Resident Information Sheet, Admission Agreement, Physician’s Report (dated 02/15/25, 02/10/22, 05/28/21, and 10/06/20), Pre-Placement Appraisal Information (dated 12/10/20), Physician’s Fax Report of Fall (dated 04/13/25, 12/25/24, 08/23/24, 08/28/24, and 11/25/23). During interviews, R1 was considered a fall risk due to their diagnosis. Additionally, during interviews, LPA was informed R1’s passing was not related to the fall. During today’s visit, LPA did not observe any Health and Safety violations. An exit interview was conducted exit interview with Administrator, Joe Saldana, and a copy of this report was provided.