complaint·May 2, 2025

INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Resident had multiple falls in care. The complaint details alleges that Resident #1 (R1) experienced multiple falls while under care. Reports show that (R1), who resides in the memory care unit, has fallen four times in the past two months and has sustained injuries on (R1)'s body. No additional information has been provided regarding this situation. Resident #1 (R1) was admitted to Regency Palms Senior Living on February 22, 2025, as indicated by their Resident Lease Agreement (dated 02/20/25) and Identification and Emergency Information (dated 02/21/25). On March 31, 2025, (R1) experienced a fall while receiving home health care from St. Victoria Home Health. The incident was reported by med-tech staff at 6:00 PM. Subsequently, on April 27, 2025, at 6:40 AM, (R1) encountered another fall that caused head injury. On May 2, 2025, between 09:30 AM and 11:30 AM, the Department interviewed a staff member identified as Staff #1, (S1) the executive director. (S1) confirmed that multiple unwitnessed falls have occurred with (R1) in the past couple of months. (S1) verified the fall dates of March 31, 2025, and April 27, 2025. (S1) claimed that the family representative for (R1) was notified of each incident and received immediate medical attention at St. Mary’s Hospital. It was further stated that (R1) was reassessed with a Resident Assessment on April 29, 2025; however, a fall management plan designed to minimize the risk of falls was not included. On May 2, 2025, between 11:02 AM and 11:10 AM, the Department interviewed a witness identified as Witness #1 (W1), the family representative for (R1). (W1) reported that staff informed (W1) about (R1)’s recent fall on April 27, 2025, which resulted in several injuries. (W1) also mentioned another fall a few weeks earlier, although (W1) could not provide the exact date and time. That previous fall caused bruises around both eyes and (W1) was notified of it. Both incidents required medical attention at St. Mary’s Hospital. On May 2, 2025, between 11:35 AM and 11:45 AM, the Department interviewed a resident identified as Resident #1 (R1). (R1) shared a recent experience of a fall in (R1)'s room that resulted in a head injury, mainly because it occurred in a familiar area of the room. (R1) claimed to have prior falls, but the specifics could not be recalled in detail. (Evaluation Report continues LIC 9099-C) As a result, Resident #1 (R1)’s Provider Communication Form (dated 04/02/25), Unusual Incident Report (dated 05/02/25), and St. Mary’s Medical Records (dated 04/27/25) confirmed (R1) sustained falls on March 31, 2025, and April 27, 2025, with injuries. A review of (R1)’s Resident Assessment (dated 04/29/25) revealed that (R1) was medically assessed after being hospitalized after a fall incident without a fall management plan. The Department observed (R1)'s wound injuries to the left forehead and bruises on the right inside forearm to confirm injuries from the April 27, 2025, fall incident. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above. Allegation #2: Facility failed to report an incident. It is alleged that the facility staff failed to report an incident involving resident #1 (R1). According to reports, the staff did not inform licensing authorities about fall incidents concerning (R1) with written incident reports. On May 2, 2025, between 09:30 AM and 11:30 AM, the Department interviewed a staff member identified as Staff #1, the executive director. (S1) confirmed that multiple unwitnessed falls have occurred with (R1) in the past couple of months. (S1) verified the fall dates of March 31, 2025, and April 27, 2025. (S1) verified that the facility failed to provide a written incident report, Unusual Incident Report LIC 624, for the incident on March 31, 2025, involving (R1) with head injuries from the fall and was admitted to St. Mary’s Hospital. During the investigation, (S1) also informed the Department of seven incidents with facility residents from April 5, 2025, to April 25, 2025, that were not submitted to Community Care Licensing (CCL) as required according to Title 22 Regulations 87211 Reporting Requirements. Based on the information gathered, sufficient evidence supports the allegation mentioned above. Based on observations, interviews, record reviews, and analysis, the preponderance of evidence standard has been met; therefore, the allegations that " Resident had multiple falls in care " and " Facility failed to report an incident. " are determined Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D. An exit interview was conducted, and Executive Director Fabiola Marciano was provided with a copy of this report and appeals rights