complaint·May 22, 2025

There is no documentation of a fall or incident prior to 1/6/2023. Interviews with former facility staff recall an incident around that date in which R1 may have fallen while being assisted by a staff person. An interview with R1 reported that a caregiver was assisting them and stated that the caregiver was unable to support R1 properly, leading to the fall. R1 fell on the wheelchair hitting the side of their body on the arm rest and fractured the ribs. R1 reported being in pain and called a family member to seek medical treatment. The lack of documentation shows that the facility staff neglected to get R1 medical care in a timely manner. The facility did not document the incident, provide timely medical care, nor communicated the incident to R1’s family. The Licensee is cited per violation of Title 22, California Code of Regulations. In addition, this violation posed an immediate Health and Safety risk to resident(s) in care. An Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that an additional civil penalty may be assessed based on Health and Safety Code § 1569.49. The above allegation(s) is found to be SUBSTANTIATED. A deficiency is being issued per California Code of Regulations, Title 22. A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met. An exit interview was conducted where this report (LIC 9099), LIC 9099D, LIC 421IM was discussed, and a copy was provided, along with a copy of the appeal rights to Administrator Matt Ryan Regarding the allegation that staff did not provide a 60-day notice prior to the rent increase, interviews with facility staff indicated that rent increases occurs every year on April 1st. However, R1's rent was increased in the month of October, however the increase was due to the level of care being increased from a Level 7 to a Level 8. Per the admission agreement the increase of care is effective immediately. Therefore, the alleged allegations has been determined Unsubstantiated. Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Administrator Matt Ryan.