Incident investigation·December 19, 2025

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to deliver findings on an investigation conducted by the department. LPA was greeted and granted entry into the facility and explained the reason for the visit. On August 25, 2025, the Department received an incident report regarding Resident 1 (R1). The incident report dated August 21, 2025, reported R1 was found on the floor in the resident’s room complaining of severe pain and was transferred to Mission Hospital. A computerized tomography (CT) scan was done at the hospital and revealed a right-sided subdural hematoma along with a left-sided subarachnoid hematoma. During the course of the investigation, the Department interviewed staff, residents and witnesses as well as reviewed and obtained documentation such as medical records and death report. Per physician report dated May 20, 2025, R1 is diagnosed with Mild Cognitive Impairment and is non-ambulatory using a walker for ambulation. Facility assessment dated July 31, 2025, lists R1 as a moderate fall risk. Service plan dated January 11, 2025, indicates that R1 requires a fall management program. Director of Health Services states R1 was checked four times per shift due to the fall risk, but the facility does not document the checks. The resident had a prior fall reported to the Department on March 04, 2025. Per facility staff interviewed, the resident did not sustain any long term changes in condition following the fall and was still able to ambulate and transfer independently while utilizing a walker. On August 21, 2025, around 12:23 PM, R1 was observed by staff who had entered the room to advise it was time for lunch. R1 reported feeling dizzy. Staff reported R1 was left sitting in their recliner when staff had exited to bring R1 their lunch. When the staff returned two minutes later, R1 was on the ground with the resident’s head leaning on the dresser. 911 was called and resident was transported to the hospital. At the hospital, the R1’s condition deteriorated CONTINUED ON LIC 809C DATED 12/19/2025 due to the brain bleed. R1 had surgery on August 24, 2025, to release pressure due to the bleed, but the resident subsequently passed on August 25, 2025. The Orange County Coroner’s office conducted an investigation, and listed the death as accidental. Per the Coroner’s report, R1’s primary cause of death is listed as traumatic brain injury, sustained days prior to resident’s death with the secondary cause as fall, same level, sustained days prior to the resident’s death. Per the Department’s Interview with Orange County Coroner, there were no concerns of abuse, neglect, drugs, or alcohol. The Department interviewed R1’s primary care physician who stated that he did not believe the facility could have done anything different to prevent the fall and the facility does an excellent job of caring for residents. R1’s family member confirms satisfaction with resident’s care. Based on record review and interviews conducted, there was insufficient evidence to prove that the facility was neglectful or demonstrated a lack of care which led to the questionable death of the resident. Therefore, the allegation is deemed unsubstantiated meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report was provided.