Complaint·December 23, 2025

Per the facility’s charting notes dated November 21, 2023, R1 had an unwitnessed fall in her bedroom. R1 was found on the floor at approximately 3:40 AM by a facility staff and was put back in her bed after not observing any injuries and R1 denying any pain. However, it was also noted that R1 was unable to explain what happened. The facility notified R1's Responsible Party via telephone. At 1:53 PM, approximately ten hours after the fall, R1’s Responsible Party came to visit and observed R1 was not behaving like herself. 9-1-1 was then called and R1 was transported to the hospital for further treatment. R1 was admitted to the hospital with a diagnosis of an intracranial hemorrhage and R1 remained in the hospital from November 21, 2023, to November 30, 2023. R1 passed away at the hospital on November 30, 2023. Per R1’s certificate of death, the listed causes of death are non-traumatic intracranial hemorrhage and hypertension. The Department conducted four staff interviews. Staff interviews conducted confirmed that R1 was placed back in her bed after sustaining her unwitnessed fall on November 21, 2023, and that 9-1-1 was not immediately called. Staff interviews also confirmed that there was a delay in calling 9-1-1 for R1 after her fall on November 21, 2023, due to R1 not complaining of any pain or declining medical attention. However, per R1’s Physician Report dated July 26, 2023, R1 was unable to manage her own treatment and was confused/disoriented at times. Therefore, R1 was unable to decide if medical attention was necessary and there should not have been a delay in approximately ten hours for 9-1-1 to be called for R1 after sustaining an unwitnessed fall. Regarding the allegation that, staff did not observe changes in resident’s condition, the following has been concluded: Based on a review of R1’s records, the Department observed that there were there were no re-assessments on file for R1 after she had three documented falls at the facility on September 17, 2023, November 9, 2023, or November 21, 2023, to determine if there was a change in condition or if more supervision was necessary. There were also no records to support that R1 was evaluated by her Primary Care Physician during this period to determine if the resident was at a high risk for falls. Furthermore, there were no documented fall prevention techniques in place despite R1 having three falls between September 17, 2023, and November 21, 2023. Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegations that, staff did not seek medical attention in a timely manner resulting in resident passing away and that staff did not observe changes in residents’ conditions. The preponderance of evidence standards has been met; therefore, the above allegations are SUBSTANTIATED. CONTINUED ON LIC9099-C See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed in the amount of $500.00. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division. An exit interview was conducted with Assisted Living Director Christina Gonzalez. A copy of the report and Appeal Rights were provided.