complaint·November 12, 2025

Per the Unusual Incident/Injury reports (UIIRs) received by the Orange County Regional Office, R1 had a total of three falls while at the facility. R1 had one fall on September 12, 2023, one fall on September 13, 2023, and had one fall on September 14, 2023. R1 was transported to the hospital after sustaining the fall on September 14, 2023, and was admitted for increasing weakness and multiple falls. Based on a review of the hospital records, R1 did not sustain any injuries as a result of the three falls. The Department conducted an interview with R1 for this complaint but R1 was unable to provide any useful information regarding the allegation. The Department also attempted to conduct an interview with R1's Responsibly Party but were unable to due to the Department being unable to reach them. The Department conducted a total of seven staff interviews. Four out of the seven staff interviewed were unable to provide any useful information regarding the allegation due to staff not recalling the incidents. Three out of the seven staff interviewed stated that increased checks were done on R1 after the first fall to try and prevent any future falls. Staff interviews conducted stated that changes to R1's apartment were recommended to R1's family to prevent future falls, however, R1's family declined the recommended changes. Staff interviews conducted also revealed that the care plan for R1 was unable to be updated to require a higher level of care for being a fall risk, due to R1 not returning to the facility after sustaining the fall on September 14, 2023. Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Tammy Joo and a copy of the report was provided.