complaint·February 12, 2026

(Continue from LIC9099) According to R1s records, facility staff will support the resident with orientation, redirection, and wayfinding. It is also noted R1 cannot leave the facility unassisted. The facility utilizes a system that activates alarmed doors when the sensor the resident is wearing is in close proximity to exiting the area. S1 stated R1 had this sensor and staff would watch R1 sit outside the front of the facility. S2 stated he/she saw R1 walk outside through the computer screen and called for staff assistance. From S2s vantage point behind the concierge’s desk, there is no line of sight to the bench in front of the facility. S3 responded to S2s call for assistance. While outside of the facility, S2 and S3 called out for R1. S3 stated, “We found R1 by the bus stop on the public street corner.” S2 and S3 did not see R1, nor did R1 say he/she fell or was injured. However, on initial assessment, S2 stated that S2 saw a wound on R1s right knee. R1 was able to elope from the facility on 09/14/2024. No supervision was being provided to R1 which allowed R1 to make his/her way to the bus stop and sustain an unwitnessed fall that resulted in serious injury. Based on observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency was cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations and is detailed on LIC 9099-D. A Plan of Correction (POC) was developed with Business Office Director, Ellen Arguello. 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 Business Office Director, Ellen Arguello, who was provided with a copy of this report, the LIC 9099-D Deficiency Report, the LIC 811 Confidential Names List, and the LIC 9058 Licensee Appeal Rights. (Continue from LIC9099A) The facility staff denied R1 exhibited signs and symptoms of serious injury upon return to the facility, and the days following the unwitnessed fall. The facility staff also denied R1 requested for emergency medical services as well. R1 received day care center services offsite. On 09/16/2024, a Licensed Vocational Nurse (LVN) assessed R1 right knee as it was scraped and swollen. A Registered Nurse (RN) documented the R1s fall at the facility on 09/14/2024. Basic wound care was provided for knee abrasion and complaints of right knee pain. During the interview with health care provider, Director of Quality and Compliance (DQC), stated R1 was seen each day at the clinic from 09/16/2024 to 09/19/2024, and the scrapes to the knee were cleansed. Documentation shows facility staff provided first aid to R1s knee on 09/14/2024, and the resident was also assessed by licensed medical professionals on 09/16/2024. Based on interviews and records review, the department has determined 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, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Business Office Director, Ellen Arguello, who was provided with a copy of this report, and the LIC 9058 Licensee Appeal Rights. (continue from LIC9099A) Also on the records, it was noted that an RN from the hospital reviewed the care plan for R1 with the facility resident services director (RSD) and reported the services delivered are consistent with the care plan. For the allegation of Staff did not follow reporting requirements, the facility submitted an incident report to Licensing and also to R1s doctor. Responsible parties were also contacted. Regarding the allegation of Unlawful eviction, records show that upon discharge to the hospital, R1 hasn’t come back to the facility. Transition of care (TOC) team met with RSD on 9/25/24 and noted that RSD understands R1 needs to be discharged from skilled nursing facility and they are willing to accept R1 back temporarily while a new facility is found for her, due to R1 having a higher level of care needed. Per facility, R1, will have to move from the assisted living side and go to memory care side. On the same day, RSD noted that a call from a family member regarding expediting R1s discharge from skilled nursing, RSD educated family member regarding discharge process and resident's care. On 9/26/24, an inter disciplinary team (IDT) contacted responsible party to discuss the recommendation of memory care placement. Responsible party agreed with the plan to move R1. Based on records review, the department has determined that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. An exit interview was conducted with Business Office Director, Ellen Arguello , who was provided with a copy of this report, and the LIC 9058 Licensee Appeal Rights.