complaint·February 13, 2026

This investigation was completed by Investigator Hector with the Investigations Branch and revealed the following: Allegation: Resident sustained a fracture while in care. It is alleged that due to neglect/lack of supervision, R1 sustained a fracture in care. During the investigation, IB Investigator Hector contacted the Ombudsman office and the Sheriff Department; neither agency investigated the incident. A facility staff (S1) that witnessed/discovered the resident fallen and submitted internal Incident Reports was interviewed. The Incident Reports confirm that R1 sustained 6 unwitnessed falls. S1 revealed that prior administration instructed facility staff to “do more safety checks” and have R1 present in the dining room more where there was more staff supervision. However, there were no additional treatment plan changes to justify keeping R1 after continuing to sustain more falls. The current facility administrator was unable to provide any documentation from the prior administration regarding treatment plan changes. Moreover, the current facility administrator confirmed the facility does not have the staff to provide 1:1 supervision and the staff to provide the proper level of supervision for R1. The medical records confirmed that R1 sustained a hip fracture. There is sufficient evidence to support the facility had a lack of supervision of R1 that resulted in R1 sustaining injury; therefore, the allegation is SUBSTANTIATED. ***An immediate civil penalty will be issued today, in the amount of $500 due to neglect/lack of supervision of R1 that resulted in R1 sustaining a left hip fracture. *** At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(f) and may be assessed at a later date. An exit interview was conducted, and a copy of this report was provided to Subashsani Kumar, Executive Director along with the Appeal Rights. The investigation revealed the following: Allegation: “Staff did not ensure a resident was properly groomed while in care.” It is alleged that on March 2, 2025, R1 was sitting in a wheelchair in front of the TV with other residents with unkempt hair, bare feet, and a runny nose. All (5) staff interviewed denied the allegation. Interviewed staff stated that caregivers use a task/ADL sheet to monitor residents' personal hygiene. Staff indicated that the residents' bathing schedule is either twice a week or as needed. If a resident refuses to shower, staff document it on the task sheet and some staff use a different way to encourage a resident to take a bath. Interviewed staff mentioned that R1 was usually in bed until early afternoon, but they ensure that caregivers help groom R1 before bringing R1 out. All residents interviewed denied the allegation and stated that staff assist them with their personal hygiene and do laundry for them regularly. Residents also denied seeing untidy residents. During the visit, LPA observed that residents were neat, properly dressed and odor free. Therefore, there was insufficient evidence to corroborate with this allegation. Allegation: “Staff did follow proper general food service requirements.” It is alleged that a resident ate dinner next to another resident with the urine bag on their table. All (5) staff interviewed denied the allegation. Staff stated that in addition to following proper food and safety procedures, they also received training about infection control and personal rights. Staff also stated that they have never seen any resident’s urine/catheter bag placed on surfaces where food is served. All (5) residents interviewed denied the allegation. Residents stated that they have never seen anyone put a urine/catheter bag on the dining table. Some residents also indicated that staff treat them with respect. During the visit, LPA did not observe any urine/catheter bag on the dining table or public areas. Therefore, there was insufficient evidence to corroborate with this allegation. Allegation: “Staff do not provide adequate care and supervision to the residents.” It is alleged that around the week of January 6, 2025, (2) residents were seen having difficulty using the community bathrooms with walkers and one of them called for help before a caregiver arrived. Staff indicated that some residents are safe to move independently with a walker and some require one-on-one assistance. Staff interviewed stated that the facility has enough staff to assist residents with their activities of daily living (ADLs). Staff stated that they perform scheduled checks especially for high-fall-risk residents. Staff stated that they received training on fall prevention, safe transfer techniques, and the proper use of walkers. Interviewed residents stated that they were not aware of this incident but confirmed that staff assist them with their activities of daily living (ADLs) such as toileting. Residents interviewed indicated that they feel there is sufficient staff to provide adequate supervision and monitoring to meet their needs. Residents interviewed indicated they feel safe and comfortable at this facility. LPA observed that the facility’s community restrooms have appropriate grab rails and enough space for a walker. Therefore, there was insufficient evidence to corroborate with the allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Subashsani Kumar, Executive Director.