Inspector’s narrative
What the inspector wrote
Investigation Revealed the Following:
Allegation:
Staff did not address a resident's change in medical condition
The details of this complaint alleges that the facility failed to re-assess (R#1) after multiple falls.
On October 30, 2025, the department conducted a review of medical records and found the following:
On January 19,2025, (R#1) was transported to Long Beach Medical Center after slipping out of their wheelchair while attempting to use the restroom. The hospital performed imaging tests that revealed no fractures. (R#1) was discharged the same day.
On February 4, 2025, (R#1) sustained a facial contusion from an unwitnessed fall in the facility and was admitted to Los Angeles Community Hospital for treatment and discharged February 7,2025.
On April 5, 2025, (R#1) sustained a hematoma due to hitting their head when transferring from their wheelchair to their bed. (R#1) received treatment at Long Beach Memorial Hospital and was discharged the same day.
On May 31, 2025, (R#1) experienced a mechanical fall in their bathroom and complained of shoulder pain. (R#1) was transported to Los Angeles Community Hospital. During this visit, imaging tests revealed that (R#1) sustained a closed, displaced fracture of the right clavicle. (R#1) was discharged the same day with documentation indicating orthopedic surgery would be scheduled. On June 5, 2025, (R#1) returned to the hospital due to injury-related pain.
On June 17, 2025, the department conducted an interview with (R#1), who stated they have vertigo and a fall risk. (R#1) confirmed they have experienced falls in the facility and injuries as a result of the falls.
On September 2, 2025, the department conducted an interview with the assistant administrator (A#1), who stated (R#1)’s Needs and Services Plan and care plan were not updated after (R#1)’s falls.
Evaluation Report continues LIC 9099-C
On June 17, 2025, the department conducted an interview with (R#1), who stated they have vertigo and a fall risk. (R#1) confirmed they have experienced falls in the facility and injuries as a result of the falls.
On September 2, 2025, the department conducted an interview with the assistant administrator (A#1), who stated (R#1)’s Needs and Services Plan and care plan were not updated after (R#1)’s falls.
On September 2, 2025, the Department interviewed two facility caregivers, (S#1) and (S#2), regarding the care and supervision of (R#1). (S#1) reported that the only change (S#1) recalled was relocating (R#1) from the second floor to a first-floor room. (S#1) confirmed they received no additional instructions or updates regarding (R#1)’s care, supervision, or monitoring requirements. Similarly, (S#2) reported that they were only told to “keep a close eye” on (R#1) but received no formal or detailed instructions regarding changes to (R#1)’s supervision or care plan following the falls. Both staff members denied being informed of any structured plan to address (R#1)’s fall risk, and neither reported receiving training or direction specific to (R#1)’s condition or needs.
Evaluation Report continues LIC 9099-C
On September 2, 2025, the Department interviewed two facility caregivers, (S#1) and (S#2), regarding the care and supervision of (R#1). (S#1) reported that the only change (S#1) recalled was relocating (R#1) from the second floor to a first-floor room. (S#1) confirmed they received no additional instructions or updates regarding (R#1)’s care, supervision, or monitoring requirements. Similarly, (S#2) reported that they were only told to “keep a close eye” on (R#1) but received no formal or detailed instructions regarding changes to (R#1)’s supervision or care plan following the falls. Both staff members denied being informed of any structured plan to address (R#1)’s fall risk, and neither reported receiving training or direction specific to (R#1)’s condition or needs.
Allegation:
Staff neglect resulted in a resident being hospitalized
The details of the complaint allege that facility staff failed to appropriately respond to changes in condition for (R#1), following multiple falls.
On October 30, 2025, the department conducted a review of medical records and found the following:
On January 19,2025, (R#1) was transported to Long Beach Medical Center after slipping out of their wheelchair while attempting to use the restroom.
On February 4, 2025, (R#1) sustained a facial contusion from an unwitnessed fall in the facility and was admitted to Los Angeles Community Hospital for treatment.
On April 5, 2025, (R#1) sustained a hematoma due to hitting their head when transferring from their wheelchair to their bed. (R#1) received treatment at Long Beach Memorial Hospital.
On May 31, 2025, (R#1) experienced a mechanical fall in their bathroom and complained of shoulder pain. (R#1) was transported to Los Angeles Community Hospital. During this visit, imaging tests revealed that (R#1) sustained a closed, displaced fracture of the right clavicle.
Evaluation Report continues LIC 9099-C
During this investigation, the department found sufficient evidence to support the above-mentioned allegation(s).
Therefore, the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be
SUBSTANTIATED.
California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D).
*Immediate Civil Penalty issued*
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, and a copy of the Complaint Report was given to Veronica Gomez/Executive Director.
