Follow-up on corrections·January 23, 2026

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced case management visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by staff and explained the purpose of the visit. On June 6, 2025, the Orange County Regional Office received an incident report regarding unwitnessed falls involving Resident 1 (R1) resulting in a closed fracture. The investigation determined the following: R1 was admitted to the facility on April 30, 2025, and was identified as a high fall risk based on the Preplacement Appraisal and Morse Fall Scale completed on April 28, 2025, by the facility staff. R1 sustained an initial unwitnessed fall on May 26,2025 and a secondary fall on May 30, 2025 per incident reports submitted to the Department. On May 26, 2025, at approximately 1:10 p.m., R1 sustained an unwitnessed fall in the common television room area of the memory care unit. R1 was found on the floor complaining of left ankle pain and was transported to the hospital for evaluation. R1 was diagnosed with a contusion of the lower leg and discharged back to the facility the same day. Hospital discharge instructions on May 26, 2025, directed the facility to ensure R1 was seen by their primary care physician (PCP) within three days. Interview with R1’s PCP confirmed the facility did not contact R1’s PCP following this incident, and no documented physician follow-up occurred until June 3, 2025. Continued on LIC809-C dated 01/23/2026 On May 30, 2025, R1’s service plan was updated to reflect increased needs, including requiring assistance with transferring and mobility. At the time the service plan was updated, R1’s physician had still not been consulted regarding R1’s initial fall. At approximately 8:40 p.m. the same day, R1 sustained a second unwitnessed fall in their bedroom and was found on the floor next to their bed. R1 was transported again to the hospital, where diagnostic imaging revealed fractures of the right inferior pubic ramus and right superior pubic ramus. Interviews conducted with three out of three facility staff members identified as being involved in R1’s care during the relevant time periods revealed that none were able to recall the last time they had seen R1 prior to the May 30, 2025, fall. One staff member reported that routine resident checks in the memory care unit are typically conducted every 20 to 30 minutes; However, no staff member was able to provide a specific timeframe or documentation verifying when R1 was last observed before being found on the floor. The investigation further determined that residents in the memory care unit do not utilize personal call pendants, although the building does have a pull cord system. However, Residents who are unable to cognitively know how to utilize the system and require assistance must verbally call out for help, requiring staff to be within hearing distance. Given R1’s documented fall risk, impaired mobility, and need for assistance with transfers, the facility did not implement adequate monitoring or supervision measures to ensure R1’s safety. Based on the totality of evidence obtained, the Department has concluded that the facility failed to provide adequate care and supervision to a known fall-risk resident by not implementing reasonable safety measures or monitoring practices resulting in R1 sustaining an unwitnessed fall and injury. The following is being cited per California Code of Regulations, Title 22. A Civil Penalty is pending determination by Community Care Licensing Division as per H&S Code 1569.49(f). An exit interview was conducted with Executive Director Yaylene Mazariegos, and a copy of this report, the LIC 809-D, the LIC 421IM and Appeal Rights were provided to the facility. A copy will be mailed to the licensee to the address on file.