complaint·April 9, 2025

(Continued from LIC9099) On 10/23/2024 at 10:20 a.m., LPA Evelin Rios initiated the complaint visit. LPA Rios conducted physical plant tour and obtained copies of the facility records such as, Personnel Report, Training Records, Unusual Incident/Injury Reports (UIRs), Preplacement Appraisal Information, Physician’s Report, Function Report, and Face Sheet. LPAs, Evelin Rios and Abeye Duguma conducted interviews with residents. On 10/23/2024 LPAs, Evelin Rios and Abeye Duguma conducted interviews with residents. Regarding the allegation that due to insufficient supervision contributed to residents sustaining injuries, it was alleged that resident #1 (R1) had multiple falls in the facility and had at least on one occasion had been on the floor for hours. Documentation such as but not limited to, Unusual Incident Reports obtained in the facility describe R1 as having multiple falls on 10/14/2024 and 10/15/2024 including on or around 5/04/2024, 7/08/2024, 9/01/2024, and 10/10/2024 resulting in R1's hospitalization While the facility, responded to R1’s falls on 5/04/2024 and 9/01/2024 by arranging for physical therapy and rehabilitation, the facility retained R1 despite knowing R1 required a higher level of care. Facility staff instead instructed R1 to activate their bedroom pull cord whenever requiring toileting assistance. On 9/20/2024, R1’s primary care physician’s office advised the facility that R1 might need to transfer to a skilled nursing facility (SNF) due to R1’s need for “constant monitoring,” but the facility retained R1 for almost another month, during which R1 sustained at least five falls. IB investigator Jose Santana’s interview with the facility’s Administrator, Imelda Villanueva justified retaining R1 because she said arrangements were already in process, as early as August 2024, to relocate R1 to a SNF. Villanueva also admitted that in the interim, the facility was not able to meet R1’s needs. The facility did not consider providing a one-on-one caregiver or obtaining a fall mat, motion sensor, or bed alarm for his safety until the time R1 could relocate. Based on the information gathered during the investigation, the allegation is deemed Substantiated at this time. An immediate civil penalty (See LIC 421C/Civil Penalty Assessment-Immediate) of $500.00 was assessed on this day of the visit for violations that resulted in injury wherein the facility failed to provide the necessary care for R1. If the Department determines that the underlying violation resulted in serious bodily injury, the licensee will be notified that an increase of civil penalties will be assessed based on Health and Safety Code §1569.49(f). Exit interview conducted. A copy of the report and appeal rights were provided.