Complaint·June 17, 2026

(Continuation from LIC9099) S1 continued towards R1’s private bathroom where R1 was observed to be lying on the floor, flat on their back. S1 reportedly contacted S2 for additional assistance. Upon S2’s arrival, R1 was assessed and staff deemed it necessary to contact emergency personnel and R1’s responsible person. Interviews conducted with staff report that R1 did not sustain any visible bruising and were observed to have a minor lump to the back of the head. Interviews conducted with R1’s responsible person confirmed that they were contacted by facility staff to where staff informed R1’s responsible person that R1 was being transported to the hospital as R1 experienced an unwitnessed fall. R1’s responsible person provided photos to the Department of R1’s face. Photos received can be described as a 6-inch bruise on the left side of R1’s face. Interviews conducted with the (8) eight staff and Resident #2 (R2) report that R1 was not observed to have bruising until after R1 returned from the hospital after the fall incident. Records review conducted of R1’s Needs and Service Plan does not indicate R1 to be a fall risk. A review conducted of the facility’s Unusual Incident Reports did not reveal additional falls sustained by R1. A review conducted of R1 medication list revealed that R1 was receiving medication that would make R1 susceptible to bruising. Therefore, the allegations of resident sustained multiple unexplained bruises while in care is deemed unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was provided to Business Office Manager Nicole Anguiano.