Incident investigation·December 19, 2023

Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced regarding the incident report dated 12/12/2023 submitted to the Department. LPA Ivey Canady met with acting administrator Latrice Ross and explained the purpose of today's visit. Community Care Licensing (CCL) received an incident report regarding Resident 1 (R1) having been discovered on the floor by facility staff. Administrator stated care staff saw R1 on the floor. R1 was trying to get into R1's apartment and could not make it. R1 was walking with a walker and R1 loss balance and fell to the floor. R1 was unable to control the walker which resulted in the fall. R1 was sent to the emergency room by facility director of care and accessed by hospital physician. According to interview with facility staff, R1 was sent back to the facility with no additional orders with no reports of pain. Based on facility staff, R1 is currently continuing normal facility routines and activities. Based on interview with facility acting administrator, R1 is an independent resident, free to enter and exit at will, and was exiting the elevator when fall occurred. No care staff witnessed the fall, yet were alerted immediately by facility housekeeper. Facility administrator is conducting an in-service training with facility care staff regarding fall prevention on 1/08/2023. Per California Code of Regulations, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left for acting administrator Latrice Ross.