complaint·January 22, 2026

The two staff stated R1 was observed to be at baseline before and after the fall. Two out of three staff stated R1's family member arrived shortly after and was explained the incident. The remaining staff did not add anything relevant to the incident occurring on January 14, 2025. Two out of three staff stated R1's family member came later to visit R1 on January 15, 2025. Two out of three staff added R1's family member believed R1 was not at their baseline and called 911 to transport R1 to the hospital. The remaining staff did not add anything relevant to the incident occurring on January 15, 2025. Interview with Administrator AD Andy Beach stated the incident was not reported to R1's Primary Care Physician (PCP). Record review revealed R1 was diagnosed with a urinary tract infection and prescribed an antibiotic. R1 returned to the facility the same day. Based on interviews conducted and record review, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of the report was left with the facility representative along with appeal rights.