complaint·December 19, 2025

Interview with a witness revealed that R1 was found unaccompanied and on the ground of the supermarket parking lot at around 3:00pm. Records collected from emergency personnel show that on April 24, 2025, at 2:56pm, emergency personnel were contacted to assist on the scene for an elderly fall at the exact address of the supermarket. R1 progress notes revealed that at 3:30pm, R1’s responsible party contacted the facility to report R1’s fall which had resulted in a fractured hip. Interview with R1 established that R1 was regularly allowed to walk freely throughout the facility including the courtyard which leads to the main road with no physical barrier. Video surveillance also revealed that as R1 was walking out of the facility, both the Executive Director and the Business Office Manager were behind R1, but video did not reveal actions taken by either to prevent R1 from leaving. Interview with the Director of Assisted Living established that R1 was regularly allowed to walk the courtyard unescorted and direct staff supervision was not consistently provided. Medical records collected revealed that R1 was diagnosed with closed fracture of right hip status post fall. The Department received information that R1 died on September 12, 2025. Official Death Certificate established that primary cause of death was hypertensive and atherosclerotic cardiovascular disease with significant condition attributing to death but not resulting in the underlying cause given was remote blunt force injury with right hip fracture while place of injury was identified as a parking lot. It was also alleged that R1 was charged for services not rendered. According to R1’s signed admissions agreement, R1 was assessed at Care Level II. Admissions agreement defines Level Care II care as 61-120 points per day of assistance with personal assistance and care services and costs an additional $2100 per month. Within R1’s Health and Services Evaluation Results completed on April 7, 2025, R1 was assessed with a total of 114 points, identifying bathing at 16 points, grooming assistance at 15 points, dressing at 20 points, toileting at 30 points, ambulation/escorting at 25 points, meal consumption as 3 at points and special care at 5 points. Additionally, in R1’s Service Plan dated April 7, 2025, R1 requires extensive assistance and requires total assistance or wheelchair escort to and from activities, meals, etc. by one staff member. Interview with multiple staff revealed R1 is regularly allowed to walk the facility premises unassisted or monitored. Interview with R1 prior to death, revealed R1 received little to no assistance while living at the facility. Based on the information collected, R1 was assessed for services to meet their individual need and such services were not provided. Based on interviews conducted, review of records, including outside sources records, a preponderance of evidence exists to support the allegation lack of supervision resulted in R1 sustaining serious injury and R1 was charged for services not rendered by facility. The allegations are therefore substantiated. Two deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). The Department has determined this violation resulted in a serious injury to the resident in care. An immediate Civil Penalty of $500.00 is charged and is noted on the LIC421IM. Additionally, two repeat violations have occurred therefore two $250 Civil Penalties will be assessed on the LIC421FC Currently, according to Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of Community Care Licensing Division. An exit interview was conducted with Administrator, 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 Administrator Kimberly Garcia, signature on this form confirms receipt of documents.