complaint·November 30, 2023

Allegation: Personal Rights/Resident Sustained injuries while in care. The investigation for this allegation was conducted by Investigator Edward Hector. During this investigation, IB Investigator Edward Hector conducted interviews with the Wise & Healthy Aging Ombudsman, Staff #1 (S-1) through Staff #2 (S-2) and Resident #1 (R-1) through Resident #3 (R-3). Investigator Edward Hector obtained and reviewed R-2’s hospital medical records. Per Investigator Edward Hector, “staff admitted that there was a history prior to the incident that showed R-2 may have needed a higher level of care. Interviews of staff, residents and Investigator observations revealed that there was a lack of available staff and staff response when requested. There is sufficient evidence to support the allegation of lack of supervision resulted in R-2 sustaining injury”. LPA Irra obtained additional documentation which revealed that R-2 had (9) falls between 03/25/21 through 05/31/21. On 05/17/21, R-2 fell and sustained a pelvic fracture. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 1 is being cited. Immediate Civil Penalties will be issued today, in the amount of $500.00 due to: Personal Rights/Resident Sustained injuries while in care. Exit interview conducted. A copy of the LIC9099, LIC9099C, LIC9099D and LIC421IM (Civil Penalty Assessment), and Appeal Rights were provided to Maria Razo/Resident Care Director Allegation: Personal Rights/Facility did not seek timely medical treatment for resident. The investigation for this allegation was conducted by Investigator Edward Hector. During this investigation, IB Investigator Edward Hector conducted interviews with the Wise & Healthy Aging Ombudsman, Staff #1 (S-1) through Staff #2 (S-2) and Resident #1 (R-1) through Resident #3 (R-3). Investigator Edward Hector obtained and reviewed S-2’s hospital medical records. Per Investigator Edward Hector, “R-2 admitted to refusing services and not always notifying staff of unwitnessed falls. Staff advised that R-2 would regularly contact R-2’s social worker for assistance, instead of facility staff. Residents confirm that R-2 would routinely not ask for help from facility staff. There is insufficient evidence to support the allegation that staff had a failure to seek timely medical attention. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted. A copy of this report and Appeal Rights were provided to Maria Razo/Resident Care Director