Incident investigation·September 16, 2025

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced case management visit to the facility in response to a self-reported Unusual Incident Report. Upon arrival, LPA Haddadin was greeted by Executive Director Susan Lee, who granted access to the facility, at which time the purpose of the visit was explained. According to the incident report, on September 12, 2025, Resident 1 (R1) sustained a maxillofacial fracture as a result of a fall. LPA Haddadin obtained copies of R1’s file, including medical records and recent hospital discharge paperwork related to the incident. Records confirmed that R1 is ambulatory and able to walk independently; however, as a precaution, R1 uses a walker. LPA Haddadin conducted interviews with four staff members, all of whom consistently reported that R1 had exited their room without the walker and was standing at their doorway when staff approached to retrieve the walker from the room. At that moment, R1 fell forward. Facility staff immediately contacted emergency services, and R1 was transported to Anaheim Regional Center, where they were treated and discharged the same day. LPA Haddadin also interviewed R1 and observed them resting in bed. When asked about the incident, R1 stated they became dizzy just outside their room. When asked about pain, R1 denied experiencing pain and stated they were preparing to attend a Bingo activity. Based on interviews and record review the preponderance of evidence has not been met; therefore the allegation is deemed unsubstantiated