complaint·October 13, 2025

Per incident report Community Care Licensing received on November 13, 2023, incident dated for November 3, 2023, facility staff observed R1 on the floor “around 5:00 AM” and reported that R1 denied of pain, however 9-1-1 was contacted due to R1 being observed with a bump on their head. R1 was transferred to UCI Medical hospital the same day. Per hospital discharge summary dated for November 6, 2023, R1 had “dementia” and was “nonverbal at baseline in a fetal position found down…next to bed with head bleeding for an unknown amount of time with laceration…and not following commands”. R1 was admitted to UCI hospital on November 3, 2023, and discharged on November 6, 2023. R1’s principal diagnosis was “mechanical GLF c/b C1-C2 fracture, right femur”. According to the hospital physician, R1 was not a surgical candidate due to R1 having “poor functional status”. Per UCI discharge summary, R1 sustained a hangman’s fracture, multiple compression fractures, and intertrochanteric femur fracture. R1 was placed on “home with home hospice” upon discharge from the hospital and was receiving continued wound care from November 3, 2023 to November 30, 2023. In December 2023, R1 passed away in the middle of the night. Based on the information gathered during the investigation and review of documents obtained the preponderance of evidence standard has been met, therefore the allegations are determined to be SUBSTANTIATED. The following is being cited and the Immediate Civil Penalty has been assessed and issued per California Code of Regulations, Title 22 Division 6 Chapter 8, per H&S Code Section 1569.49(f). An exit interview was conducted with AD Rodriguez. A copy of this report was explained, and appeal rights were provided during the visit.