complaint·January 16, 2026

assist with cueing and maintaining a safe environment in the resident’s room as well as adequate lighting and proper footwear. Additionally, it was noted under “Behaviors” for staff to keep the resident with them during daytime hours and encourage activities. All staff interviewed indicated R1 was either in the common area with staff or checked at least every two hours if not in common area. Medical records obtained following R1’s hospitalization on September 09,2025, revealed they sustained a scalp laceration which was repaired with one staple. Imaging revealed no evidence of an acute traumatic injury. On September 12, 2025, after sustaining their second fall, medical records obtained revealed a small volume left frontal subarachnoid hemorrhage and an acute minimally displaced fracture of the left zygomatic arch. Upon return from the hospital additional fall preventions were put in place for R1 including a lowered bed; wheelchair; and a nighttime one on one care companion from the period of September 14, 2025, through September 23, 2025, for the hours of 10PM to 8AM. Staff interviewed reported that since the resident started utilizing the lower bed, there have been no other falls. The review of Huntington Beach Fire Department records showed staff called 911 to request medical assistance for both unwitnessed falls. The resident had three prior falls at the facility resulting in no injury for the dates of September 03, 2025; September 05, 2025; and September 08, 2025. Based on record review and interviews conducted, the Department is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator, and a copy of this report and confidential names list was provided to facili ty