complaint·August 8, 2025

According to R1, R1 called out for help and could not reach their call pendant. R1 stated no one arrived to assist until about 7:30am on September 29, 2022. Interview with multiple training-staff revealed that staff are expected to check all assigned residents’ multiple times per night. Interview with responsible parties revealed that the facility advertised itself to them as checking in on assisted-living residents every two hours. Interview with Director of Assisted Living corroborated that facility staff are to check resident’s multiple times per night. According to records collected, the night of September 28, 2022, Staff 1 (S1) was assigned to R1’s floor. During an interview, S1 stated they did not check in on R1 the night of the incident and S1 had been told that R1 did not require continuous visual checks. Interview with Staff 2 (S2) established that on the morning of September 29, 2022, R1 did not call S2, as usual, for escort assistance to breakfast. S2 stated as they went to check on R1 they heard R1 yelling for help at about 7:10am, S2 stated that when they opened the door, they observed R1 in their room on the floor leaning against the patio door. S2 then proceeded to contact Staff 3 (S3) to assess R1 for injuries; no serious injury was found. Based on interviews and records collected, a preponderance of evidence exists to support the allegation. The allegation is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Executive Director Kimberly Garcia, and a Plan of Correction was jointly developed. A copy of this report, LIC811, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to xxxxxx, signature on this form confirms receipt of documents. Details of the allegation state that on September 28, 2022, R1 initiated their nighttime routine, and received medication from Medication Technician at 10:00pm. At about 10:30pm, R1 got up from their couch while using walker and fell sideways. According to R1, R1 called out for help and could not reach their call pendant. R1 stated no one arrived to assist until about 7:30am on September 29, 2022. Interview with Staff 2 (S2) established that on the morning of September 29, 2022, R1 did not call S2, as usual, for escort assistance to breakfast. S2 stated as they went to check on R1 they heard R1 yelling for help at about 7:10am, S2 stated that when they opened the door, they observed R1 in their room on the floor leaning against the patio door. S2 then proceeded to contact Staff 3 (S3) to assess R1 for injuries. Interview with S3 established that S3 did a full body check of R1 and found no abnormalities. S3 stated that R1 did not express any pain and was given an as needed pain medication and an ice pack. Based on LPA's interviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director Kimberly Garcia to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.