Follow-up on corrections·May 8, 2026

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to deliver findings on an investigation conducted regarding an incident report received by the Department on March 24, 2025. LPA was greeted and granted entry into the facility and explained the reason for the visit. Per the Incident report, on March 17, 2025, Resident 1 (R1) had been found on the floor with a red eye and blood on their nose. 911 was called and the resident was transported to the Hospital where resident was diagnosed with a closed blowout fracture of right orbital floor, fracture of L5 lumbar vertebrae and a fractured rib and left clavicle. The resident moved to Belmont Village Assisted Living on July 31, 2023. Per pre-placement appraisal dated August 03, 2023, R1 required minimal assistance for activities of daily living (ADL’s). Per physician report dated March 24, 2025, R1 had a diagnosis of Parkinson's Disease, Progressive Supranuclear Palsy (A rare, degenerative brain disease that affects movement, balance, and eye control) and had mild cognitive impairment. R1 utilized a walker for mobility. On October 24, 2024, facility staff noticed a change in condition as the resident became more confused and disoriented while becoming progressively unsteady and beginning to have falls. R1 began to fall in November 2024, without injury, and was initially re-assessed December 10, 2024. Resident was subsequently re-assessed four more times between December 10, 2024, and March 20, 2025, after additional falls. Management had R1 medically evaluated by a mobile physician who visited the facility two to three times weekly checking on residents including R1. The physician adjusted R1’s medications and staff continued to monitor them for changes. Continued on LIC 9099C DATED 05/08/2026 During R1’s residency at the facility, they had approximately 14 falls that were reported to the Department which occurred during the evening and early hours. R1 was not diagnosed with sundowning, however, staff reported the resident was restless at night and had difficulty sleeping. On March 17, 2025, staff reported finding R1 in front of their apartment with a red and purple eye and blood around the nose. 911 was activated and the resident was transferred to the Hospital where they were diagnosed with a sustained closed blowout fracture of the right orbital floor; fracture of the L5 lumbar vertebrae; and fractures to rib and the left clavicle. R1 was discharged and returned to the facility same day with orders for follow-up appointments with primary care and orthopedic physicians. On March 26, 2025, at about 11:39 PM, R1 was found on the floor by a caregiver and 911 was activated. R1 was sent out to the hospital, and no additional injuries were noted. The resident was discharged from the hospital at about 6:30 AM and returned to the facility. The resident’s family was contacted and a companion from a Homecare Agency was hired to accompany R1 between 11 PM and 7AM for additional supervision. Five out of seven staff and Administrator confirmed R1 was provided with fall prevention tools including a bed alarm, floor mat and motion cameras in the room as well as a pendant and a bracelet for R1 to use if remembered. Administrator stated having multiple conversations with the resident’s family regarding a higher level of care, hiring a companion and the option of moving to a smaller environment. R1’s family confirmed the conversations. The facility provided measures to alert staff if R1 had a fall, however, R1 still had 14 falls within a five-month period. While the facility implemented fall risk measures to alert staff when R1 had falls, measures implemented failed to ensure R1’s safety. R1 required additional supervision and a higher level of care to protect them from repeated falls. The facility was unable to mitigate R1’s falls with measures utilized and additional mitigation measures such as a full-time companion were not implemented. R1 was placed at a board and care on March 31, 2025, where R1 is reported to be doing well, and no falls have been reported. 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 sufficient 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 Administrator Anie Becker and a copy of this report was provided.