Complaint·June 2, 2022

wasn’t aware of any residents sustaining injuries from a fall but later admitted R1 sustained injuries last month and only a bruising. She stated resident did not need to go to the hospital and R1 was seen by home health nurse the following day. LPA interviewed assistant administrator Cesilia Torres and she stated was not aware of any resident falling last month. LPA interviewed staff S1, stated there was no resident that had fell and suffered injuries but later admitted to R1 falling but stated did not see what happened but was informed of the incident. LPA interviewed staff members #2-#5, they stated R1 had fell last month and had suffered bleeding and bruising to face. LPA interview residents #1, stated suffered injuries to face the later part of April. R1 stated was assisted by a caregiver, who was supposed to transport him from the wheelchair to the bed. R1 stated caregiver proceeded to hold up by the shirt and fell onto the bed rails two times and face was injured. R1 stated caregiver kept apologizing and applied ice to face. LPA interviewed residents #2-4, they stated wasn’t aware of a resident falling. LPA obtained copy of the report log and R1 had an eye injury and was bleeding. Based on documents and interviews the above allegation is substantiated. Regarding allegation: Staff did not properly report an incident regarding a resident. On 5/17/22 and 5/27/22, LPA interviewed Bells Naygas. She stated they did not complete an incident report for R1. She stated they haven’t done an incident reports in a long time but will start submitting them. LPA interview Cesilia Torres and she stated no incident reports was completed regarding the incident. LPA interviewed staff members # 1-5 and no incident report was made regarding R1. They also stated for incidents that happen they will log in a notbook in the office and will report to staff in charge. LPA observed log book in the office of R1 incident and there was no incident report made. Based on documents and interviews the above allegation is substantiated. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D and LIC 421 FC-Failure to Correct and Repeat Violation. Exit interview was conducted and a copy of the report and appeal rights was given to Cesilia Torres..