complaint·January 16, 2026

Based on staff interviews it was revealed R1 transferred to another licensed facility and later returned to this facility, Jasmin Terrace of Yucca Valley. Overall, interviews revealed, that the facility was short-staffed at the time of this incident. Initially it was alleged the fall was unwitnessed. However, during the course of the investigation a witness was identified. Staff reported hearing R1 call out for help. As staff was walking towards R1 to provide the assistance, they witnessed R1 fall to the floor and suffer the laceration. Staff immediately called 9-1-1 and R1 was transported to the hospital. Staff interviews further revealed a change in condition of R1. R1 went from being independent and needing minimal assistance with activities of daily living to being described as “lethargic, and more medicated”. An updated Needs and Services plan was completed on 04/08/2020. The updated plan noted R1 to be a fall risk, due to poor safety awareness. Frequent checks were reported to have been implemented as an intervention method. Overall, interviews with staff revealed a staff shortage and staff not being properly trained. Therefore, the allegation of staff neglect resulted in resident’s death is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means that 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. An exit interview was conducted, and a copy of this report, LIC 9099-C, Confidential Names list (LIC 811), and appeal rights were reviewed and provided to AA Molina.