complaint·November 24, 2025

Resident 1’s (R1) Initial assessment dated July 23, 2019 notes that R1 needs no additional status checks, needs minimal prompting/ cueing/ reminding, requires one person assist/ escorting for meals, is independent with transfers and was marked zero under fall concern. R1’s Physician’s Report dated July 25, 2019 notes R1 having diagnosis of Dementia and Gait imbalance listed under other conditions. R1’s recent appraisal dated August 10, 2019 noted R1 to be in good health, some confusion/ forgetfulness and Ambulatory. R1’s previous Appraisal dated July 30, 2019 noted R1 to be in fair health, forgetfulness, weak physical disabilities and Non-Ambulatory. Interviews with Staff members stated that two of five staff members interviewed recalled R1 being independent, lived with wife at facility and was in Assisted living for period of time. Three of Five staff members interviewed were not aware of R1 and their care needs. Based on conflicting information gathered by records reviewed and interviews conducted, the allegation facility had lack of care and supervision was deemed UNSUBSTANTIATED, meaning although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported. Regarding allegation facility failed to assess resident for change in condition, during record review Department observed initial Assessment dated July 23, 2019 prior to R1 moving into facility on August 16, 2019. Department did not review any additional assessments in residents file. Department reviewed a incident report dated May 10, 2020 in which R1 had a unwitnessed fall inside apartment. Report stated that facility contacted Emergency Personnel and R1 was transported to hospital. Incident report did not notate whether R1 has had 2 or more falls within past 30 days. Report noted that R1 had a change in condition and would be reassessed prior to returning to community and be placed on 48 hour alert charting. Incident report also notated that R1’s service plan would be updated upon return. Resident did not return back to facility and facility was notified of R1’s passing June 3, 2020. Department reviewed Facility Death Report dated June 3, 2020 which stated that R1 was sent out to hospital on May 10, 2020 after a fall in facility. Report noted that R1 was transferred to a Rehabilitation hospital on May 23, 2020 for diagnosis of MRSA and gangrene to bilateral feet. Report noted on June 3, 2020 family contacted facility of R1’s passing. Department did not observe any additional incident reports for R1. CONTINUED ON 9099C Interviews with staff members stated that two of five staff members recall R1 having a fall and being sent out to hospital. Interviewed staff members also mentioned that they were unaware of R1 having a change of condition. Based on information gathered, the preponderance of evidence has not been met meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported, therefore the allegation is deemed UNSUBSTANTIATED Regarding allegation facility failed to provide timely medical attention. Department conducted investigation into allegation and revealed the following: Resident 1 (R1) had one incident report in profile dated May 10, 2020, stating R1 had a unwitnessed fall inside apartment. Report stated that facility found R1 at 10:35AM. Report noted that R1 was alert and verbally responsive. Report stated that facility contacted Emergency Personnel and R1 was transported to hospital by paramedics at 10:45AM. Report noted that facility contacted family who is Power of Attorney, Primary Physician and Nurse Practitioner of status. Facility unable to provide call logs due to logs being reset after period of time. Initial complaint was received in July 2021 and time duration of calls are no longer on record. Interviews with staff members revealed that Five of five staff members state that staff are expected to answer pages between seven to ten minutes. Staff members interviewed were not the first responder staff at time of R1’s incident. Interviews with residents revealed that Seven of Ten residents have had to use a pendant and staff have arrived on average between five to ten minutes. Based on Record review and interviews conducted although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported, therefore the allegation is deemed UNSUBSTANTIATED An exit interview was conducted with Business Office Manager and Copy of report was provided R1’s Assessment dated July 23, 2019 notes under ambulation that R1 requires one person total assist or wheelchair escort to and from activities. R1’s Morse Fall Scale noted R1 has a history of falls. Incident Reported Dated May 10, 2020 notes R1 had a unwitnessed fall inside bedroom and R1 was found between bedside and bathroom floor. Incident report also noted that R1 had general weakness. Department did not observe any needs and service plan for R1 or other incident reports for R1. Information provided by Witness 1 states R1 had a fall in March of 2020 in which R1 suffered small abrasions from fall. Witness states Facility did not update care plan after fall. Witness stated that R1 had a fall in May of 2020 and as a result of fall suffered a T12 Fracture in the middle of the back. Witness stated that R1 required surgery as result of fall. Based on information gathered, the preponderance of evidence has been met deeming the allegation Facility failed to develop fall prevention plan SUBSTANTIATED. See LIC 9099 for cited deficiencies as per Title 22 Division 6 of California Code of Regulations. An exit interview was conducted with Business office manager and a copy of report, along with Appeals rights, and copy of LIC 811 confidential names was provided.