Incident investigation·November 24, 2025

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on October 23, 2025, regarding Resident #1 (R1). LPA met with Administrator (AD) Brisseth Arrellano and Staff #1 (S1) Ted Dawit and explained the reason for today’s inspection. During today’s inspection, LPA inspected the facility, interviewed AD, staff, and residents, and requested and reviewed copies of the resident roster, staff roster, R1’s Medical Records dated October 18, 2025, R1’s Physician’s Report dated October 14, 2025, R1’s Personal Service Plan dated September 13, 2025, and R1’s Personal Service Plan dated October 23, 2025. Per the incident report received in the OCRO on October 23, 2025, on October 18, 2025, R1 had a fall at the facility and sustained a right toe fracture. LPA reviewed R1’s Medical Records dated October 18, 2025, which indicate R1 sustained a closed displaced fracture of the great toe. LPA interviewed AD who stated that R1 is a fall risk due to their multiple sclerosis which flares up and makes them unsteady, R1 does a good job keeping the facility informed of these flare ups and asking for extra care when necessary, and R1 has had multiple falls while at the facility but this is the first fracture R1 sustained. LPA reviewed R1’s Physician’s Report dated October 14, 2025, which indicates R1 has active progressive multiple sclerosis, Parkinson’s disease, and neuropathy, is non-ambulatory due to physical condition, but does not need assistance with bathing, dressing, eating, or toileting. LPA reviewed R1’s Personal Service Plan dated September 13, 2025, which indicates R1 is able to shower themselves but assistance was added for when R1 requests assistance, R1 is able to use the bathroom without assistance, escorts were temporarily added during a flare up of R1’s multiple sclerosis, and R1 is on the facility’s standard fall prevention plan. Per AD and facility staff, R1 was at a skilled nursing facility for over a month due to a multiple sclerosis flare up and returned to the facility on October 15, 2025, facility staff reassessed R1 to require additional care prior to R1 returning to the facility on October 15, 2025, and additional care was added to R1’s Personal Service Plan. LPA reviewed R1’s Personal Service Plan dated October 23, 2025, which documents the care services provided to R1 as of their return to the facility on October 15, 2025, and noted that assistance with emptying the commode and escorts were added. Per AD, R1 had a commode near their bed, R1 is able to get out of bed and to the commode on their own, but on October 18, 2025, R1 must have had a symptom of their multiple sclerosis and fallen on the way to the commode, injured their toe, and was taken to the hospital for treatment. Per facility staff, R1 has been receiving home health services three times a week for the toe injury and is not complaining of pain and R1’s room has been decluttered as clutter may have also played a role in R1’s fall. LPA interviewed R1 who raised no concerns over the care they receive at the facility. The information obtained did not corroborate lack of care and supervision causing R1’s fall as the facility regularly updated R1’s Personal Service Plans and added assistance where necessary to try to address R1’s chronic and evolving fall risk due to their multiple sclerosis. There were no deficiencies observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.