complaint·February 13, 2026

(Continue from LIC9099) To investigate these allegations, the Department conducted an onsite facility inspection, reviewed facility and medical records, reviewed incident reports, and conducted interviews with facility management staff, direct care staff, and outside sources. The Department also reviewed medical provider records and hospital records covering the relevant time period. Through these investigative methods, the Department assessed the facility’s compliance with applicable laws and regulations and evaluated the care and supervision provided to R1. According to the complaint, staff failed to provide adequate supervision to R1, resulting in repeated falls, including a bathroom fall involving spilled mouthwash and a courtyard fall where R1 was found outside without staff present. It was further alleged that R1 sustained serious injuries including a cervical fracture and head injuries requiring emergency medical evaluation and treatment. Resident Background A review of R1’s facility and medical records showed R1 was admitted to the facility in 2021 and had diagnoses including dementia with cognitive impairment and unsteady gait. Records documented fall risk, wandering behavior, and need for assistance with activities of daily living, including bathing, dressing, toileting, and transfers. Medical assessments and physician records documented that R1 had an unsteady gait and was considered a fall risk. Records showed R1 sustained a cervical spine fracture in April 2025 and thereafter required use of a cervical collar and ongoing fall precautions. Physician follow-up notes repeatedly documented fall risk, neck injury, and continued need for monitoring and protective interventions. Facility Needs and Services Plans reviewed during the investigation documented that R1 was a high fall risk, required supervision, and that staff were to monitor R1 for changes in gait and balance, ensure use of assistive devices and cervical collar, supervise due to wandering behavior, and be aware of R1’s whereabouts at all times. (Continue at LIC9099C) (Continue from LIC9099C) Investigative Findings The Department reviewed facility records including resident assessments, Needs and Services Plans, incident reports, staffing information, and medical and hospital records. Records and interviews confirmed that R1 experienced three separate falls within approximately a three-month period resulting in injuries and hospital evaluations. First Fall — April 23, 2025 (Bathroom Incident): Facility incident reports and management interviews documented that R1 was being assisted by a caregiver in the bathroom with brushing teeth. Mouthwash was provided, the container was knocked from the caregiver’s hand, liquid spilled on the floor, and R1 stepped backward, slipped, and fell onto a walker. R1 sustained a laceration and neck injury and was transported to the hospital. Hospital records confirmed a cervical spine (C2) fracture. After returning to the facility, R1 was placed in a cervical collar and identified as high fall risk. The Needs and Services Plan was updated to include increased monitoring and fall precautions. Second Fall — June 8, 2025 (Bedroom Incident): Facility incident reports and medical records documented that during overnight rounds R1 was found on the floor next to the bed by staff. A medication technician assessed R1 and noted a head injury. R1 was transported to the hospital. Hospital and physician records documented head injury findings and continued cervical spine concerns, with continued cervical collar orders and fall precautions. Third Fall — July 19, 2025 (Courtyard Incident): Facility incident reports, staff interviews, and nursing interview confirmed that R1 was found on the ground in the courtyard with a walker overturned nearby. The fall was unwitnessed. Staff assessment documented a bump to the back of the head and R1 was transported to the hospital for evaluation. Hospital records confirmed emergency evaluation following an unwitnessed fall. Staff interviews confirmed that caregivers were not consistently present outside with residents and that residents were at times in the courtyard without direct staff supervision. (Continue at LIC9099C) (Continue from LIC9099C) Staff and Management Interviews: Management staff acknowledged the three falls and confirmed that R1 was identified as high fall risk after the first serious injury. Management reported that care plans were updated and increased monitoring was expected. However, staff interviews showed inconsistent recall regarding who was assigned to supervise R1 at the time of the courtyard fall. At least one staff member reported discovering R1 already on the ground outside without knowing how long R1 had been there. Nursing staff stated that caregivers are not always outside with residents due to other assigned duties inside the unit. Medical Records: Hospital and physician records confirmed repeated fall-related evaluations, cervical spine fracture, head injuries, continued cervical collar use, and repeated physician orders for fall precautions and supervision. Outside provider notes repeatedly referenced fall risk and the need for continued monitoring. R1’s Needs and Services Plans required supervision, wandering monitoring, fall precautions, and staff awareness of R1’s whereabouts at all times. Despite these written interventions, records and interviews confirmed that R1 was found alone after at least one unwitnessed outdoor fall and experienced repeated falls after being designated high fall risk. Conclusion Based on the evidence obtained through interviews, record reviews, and medical documentation, the Department determined there is sufficient evidence to substantiate the allegation that a lack of supervision resulted in R1 experiencing multiple falls resulting in serious bodily injury. Review of records disclosed that R1 was assessed as a high fall risk and required supervision and monitoring; however, supervision was not consistently provided. R1 sustained a cervical fracture and additional head injuries following unwitnessed or insufficiently supervised incidents. Continue at LIC9099C) (Continue from LIC9099C) The Department finds the allegation substantiated, meeting the preponderance-of-the-evidence standard. A deficiency was cited under Title 22, Division 6, Chapter 8 of the Californi a Code of Regulations and is detailed on LIC 9099-D. A Plan of Correction (POC) was developed with Program Director, Karen Pultorak . An immediate civil penalty of $500 was assessed today. In accordance with Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Community Care Licensing Division. An exit interview was conducted with Program Director, Karen Pultorak who was provided a copy of this report, the LIC 9099-D Deficiency Report, the LIC 811 Confidential Names List, LIC411, and the LIC 9058 Licensee Appeal Rights.