complaint·September 25, 2025

(Continued from LIC 9099) On May 13, 2025, Resident #1 (R1) had an unwitnessed ground level fall. It is unknown what time of night this fall occurred. Two of two Staff interviewed stated R1 was put to bed between 8pm and 9pm and was not checked on until the next morning. Per interviews with two of two staff & Licensee, the facility does not have awake staff at night. At 8:15am on May 14, 2025, Staff #1 (S1) and Staff #2 (S2) found R1 on the floor with a cut above R1’s left brow. Staff picked R1 up from the ground and placed R1 in a wheelchair. Staff then proceeded to clean the bedroom of the blood on the floor. After cleaning the room, staff contacted the Licensee Lawrence Lindsey, who then called 911. Hospital records obtained show Paramedics were dispatched at 9:02am and arrived on scene at 9:07am. Due to S1 and S2 not immediately calling 9-1-1 there was an approximate 52 minute delay in R1 receiving medical attention. Paramedics reported that upon arrival, R1’s room was cleaned of blood but the resident was covered in dried blood on their hair, face and body. R1 was transferred to UCI Medical Center after paramedics observed a hematoma with 2 cm laceration to the head; and scattered bruising in various signs of healing on R1. Per medical records obtained, R1 was diagnosed with a closed fracture to a right rib; subdural hematoma; intraventricular hemorrhage; impaired mobility; and dementia. Per R1’s family, R1 has had a history of recurrent falls since December 2024 and correlating with Urinary Tract Infections (UTIs). Family informed Licensee that R1 wandered at night and had been working with R1’s Primary Care Physician to manage insomnia with medications. During interview with Licensee, Licensee acknowledged knowing R1 had a tendency to wander at night and was a fall risk. Despite, knowing R1’s wander behavior, no additional staff was provided to ensure R1’s safety while wandering. When asked about fall prevention methods, Licensee stated a fall mat had not been implemented due to R1’s family not providing one and was unaware if bedrails had been ordered for R1. Licensee reported they were unaware if R1 had a pendant to call for help. R1 was discharged to a Hospice Facility where they passed away on April 29, 2025. Per Death Certificate, R1’s cause of death is listed as traumatic intraventricular hemorrhage. Based on interviews conducted and records reviewed, the preponderance of evidence has been met. The allegation that the Resident sustained unexplained injury while in care due to lack of care and supervision is substantiated. The facility is being cited per Title 22, Division 6 of the California Code of Regulations. (Continued on LIC 9099-C1) (Continued from LIC 9099-C) A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(e) An exit interview was conducted with Maricel Lindsey, Administrator, and a copy of this report, 9099-D, LIC421IM, LIC811 Confidential Names, and Appeal Rights were left at the facility.