complaint·June 16, 2025

R1’s attending physician ordered lab work for R1’s lumbar area. Hospital records dated September 8, 2023, revealed lab results showed R1 had a diagnosis of Diffuse Osseus Demineralization which according to Mayo Clinic is a process that causes mineral loss in bones making them more prone to fracture and moderate to severe stenosis, which is pain in the spine. Per Orange County Huntington Beach Hospital X-ray records dated September 8, 2023, shows no bone fractures and no joint dislocation. Attending physician reported no significant tenderness over both regions, leading physician to believe these were old fractures. R1’s evaluation was consistent with soft tissue injury and consistent with bony injury. R1’s left hand and shoulder were cleaned. Hospital discharge papers dated September 8, 2023 , indicated R1 was discharged back to facility same day. Three of four staff interviewed stated that it is possible that the wheels on R1’s bed may have not been locked. Four of four staff confirmed that staff use left side of R1’s bed to assist with Activities of Daily Living (ADL’s) and during assistance the front wheels are taken off lock for staff members to have better access to R1. Interviews revealed that all four of four staff members confirmed that R1’s bed was pushed away from wall. Three of four staff interviews revealed that R1 is a restless sleeper. Interview with R1 confirms that staff forgot to lock the wheel of bed causing R1 to roll out of bed. It was observed that when wheels were locked , bed was hard to move out of place. However, if only one front wheel was unlocked , R1’s bed moved with ease in this position. Based upon Medical Records, interviews, and observations the allegation that Lack of care and supervision resulted in resident’s fall and soft tissue injury revealed that the preponderance of evidence has been met and was found to be SUBSTANTIATED. See LIC9099-D for cited deficiencies and immediate civil penalty as per Title 22 Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49. An exit interview was conducted with Cherry and Jay Paranguo. A copy of this report, along with LIC9099-D, Appeal Rights, Civil Penalty Assessment-LIC 421 IM and the LIC 811, identifying confidential names were provided and explained.