Inspector’s narrative
What the inspector wrote
According to hospital medical records, resident (R1) was admitted to the hospital on July 30, 2025, after reportedly being pushed by another resident (R2) and falling. R1 was diagnosed with right fourth (4
th
) through eighth (8
th
) rib fractures and right hemothorax. R1 was discharged from the hospital on August 1, 2025. Emergency Medical Services (EMS) records indicated that a staff (unknown) informed them that R1 went into R2’s room and R2 pushed R1 out of their room causing the fall. The Unusual Incident/Injury Report LIC624 indicated that the incident occurred at approximately 7:30am and R1 verbalized that they were pushed by R2. R2’s Behavioral Expressions Monitoring Log indicated that, on July 30, 2025, R2 was agitated, anxious, and frustrated by R1 going into their apartment. R1 was found on the floor and had an unwitnessed fall. R1 indicated that R2 pushed them. R1’s Daily Log, dated July 30, 2025, indicated that R2 pushed them down. According to staff schedules and timecards, there were three (3) care staff present at the care home, with no med tech on duty, at the time of the incident on July 30, 2025. Staff interviews indicated that, due to the facility not having a med tech on duty, staff (S2) was responsible for passing medications. Staff interviews indicated that S2 was pulling medications at the time of the incident between R1 and R2 leaving two (2) care staff available to assist residents. Interviews with staff (S3) and S2 indicated that, upon response to R1’s fall, R1 informed them that they were pushed by R2. Staff interviews indicated that the incident between R1 and R2 was unwitnessed. However, staff interviews also indicated that the facility was aware of R2’s aggressive behaviors and did not ensure there were enough staff scheduled based on the care needs of the residents.
Based on interviews conducted and documentation obtained, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiency is being cited on the attached 9099-D page. As a result of the resident's serious bodily injury, an immediate civil penalty per Health and Safety Code § 1548 in the amount of $500 was assessed on an LIC809 provided on February 19, 2026 for a violation that the Department determines resulted in the injury or illness of a person in care. An additional civil penalty assessment is under review and a determination is pending. LPA will return on a future date to assess an additional civil penalty if warranted.
Exit interview conducted. A copy of the report and appeal rights provided.
and S5) indicated that the caregivers and med techs on duty will make sure all residents attend mealtimes. Interviews indicated that, if a resident is not present, staff will locate the resident to see if they want to join. If any refusals or a resident is out of the facility, the med tech will document in the resident’s progress notes. R1’s progress notes dated May 1, 2025-July 26, 2025 had no indication of mealtime refusals.
Interview with S1 indicated that R1 always appeared clean and showered. Interviews with S1, S4, and S5 indicated that the facility has a shower log that the facility follows. S4 and S5 indicated that they have never witnessed a resident that appeared to need to be bathed. S4 and S5 indicated that, if a resident refuses showers, care staff will attempt several times or may try a change of face so a resident will take their scheduled shower. Staff indicated that they keep a shower log indicating when showers were given. LPA attempted to obtain the shower log for R1. However, according to the Regional Health and Wellness Director, Karen Silva, the facility does not keep shower logs passed 90 days. R1’s progress notes dated May 1, 2025-July 26, 2025 had no indication of shower refusals. LPA observed that the facility has a current shower schedule as well as a skin check shower sheet used when providing showers.
On November 25, 2025, December 11, 2025, and December 23, 2025, LPA toured the facility, which included all common areas and five (5) resident rooms. LPA observed the facility to be free of odor, clean, and in good repair. On December 11, 2025, LPA observed housekeeping cleaning in one of the facility hallways. Interview with S1 indicated that they never observed R1’s room to be dirty. S1, S4, and S5 indicated that housekeeping is good at ensuring the facility, including residents’ rooms, are clean. S1, S4, and S5 indicated that, if a resident has an incontinence accident, staff will clean up the resident and housekeeping will clean the floors, if needed. Staff also indicated that any linens or clothing will be laundered.
LPA visited the facility on multiple dates between November 25, 2025-January 14, 2026 and observed care staff providing care to residents, residents either waiting for mealtime or eating at mealtimes, and residents appeared clean wearing laundered clothing. The facility was also clean and in good repair.
Based on observations made, interviews conducted, and documentation obtained, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited.
Exit interview conducted. A copy of the report was provided.
