Incident investigation·February 5, 2025

On February 5th, 2025 Licensing Program Analyst (LPA) William Vanegas made an unannounced visit for the purposes of a case management visit due to a Special Incident Report (SIR) received by the Orange Regional Office. SIR stated that resident sustained a small spinal fracture due to a fall that occurred at the facility. Upon arrival LPA Vanegas was greeted and granted entry to the facility by Care Giver (CG) Maria Garcia and LPA Vanegas explained the purpose of the visit. LPA Vanegas reviewed resident's file, resident's discharge paperwork, and two staff files that were present at the time of the incident and reviewed the following. Per resident discharge paper work resident was diagnosed with a Lumbar Vertebral Fracture. Per residents physician report resident is non-ambulatory and requires assistance with activities of daily living (ADL). Resident is also diagnosed with dementia. Per LPA Vanegas review of staff files, both staff members that were present are trained on care for individuals diagnosed with dementia, and postural supports. LPA Vanegas interviewed staff member that was present and a staff member that was not present and obtained the following information. Resident had just eaten dinner right before the fall, he was transferred from the dinning table to the living room couch. He was sitting close to the edge of the sofa and staff members were in the kitchen where they still had visual of the resident however they noted him scooting closer to the edge of the couch and observed him sliding down the couch where he subsequently fell and sustained his injury. LPA Vanegas attempted to interview resident however he could not recall the incident. Resident stated that he feels safe here, and that the staff treat him with respect, and he enjoys living here. Based on today's observations and interviews there is no risk to the resident's health or safety. No deficiencies will be cited based on title 22 regulations. An exit interview was conducted and a copy of this report was left at the facility