Incident investigation·February 26, 2025

At approximately 10:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Business Office Director (BOM), Ditter Vasquez . The purpose of the visit was to follow up on an incident report that was self-submitted to Community Care Licensing (CCL). Incident Report 1/SOC341: CCL received an incident report and SOC341 on 02/25/2025. Reports stated that on 02/21/2025, the facility received a notice from their fall-detection camera system. Facility reviewed camera system which showed Staff Member 1 (S1) grabbing Resident 1 (R1). Reports stated that S1 was shown to be trying to clean R1 after using the bathroom and that R1 was resistant to receiving care. R1 was seen falling backward hitting their head against their bedroom furniture. Reports stated that S1 did not report the fall. On 02/25/2025, Staff Member 2 and Staff Member 3 (S2 and S3) conducted an assessment of R1. Facility made all notifications per Title 22 Regulations. Reports stated that S1 was currently suspended pending internal investigation. LPA discussed with BOM and facility nurse the importance of having a resident evaluated by medical personnel when a fall occurs and results in a head injury. LPA obtained additional documentation related to the incident. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Business Office Director. Signature on form confirms receipt of documents.