complaint·June 4, 2025

According to Staff 1 (S1) on April 28, 2023, between 7:30pm and 8:00pm, R1 was scheduled to receive a shower. S1 proceed to ask Staff 2 (S2) for assistance in transferring R1 from wheelchair to shower chair. Interview with S2 revealed that S2 assisted S1 in the transfer and left S1 alone to bathe R1. S1 stated that minutes later, S1 reached for a washcloth and as they reached away from R1, R1 fell from shower chair and hit head on the floor. S1 proceed to call for assistance from S2, Staff 3 (S3) and Staff 4(S4). S3 then assisted S1 and S2 in proving first aid to R1 and S4 contacted emergency personnel. R1 was then taken to be medically evaluated and received sutures to left forehead above the eye. According to medical records on April 29, 2023, at 2:56 am, R1 was discharged and returned to the facility with a diagnosis of laceration to the top of the left forehead. Interview with an outside source, confirmed R1 received medical care post fall. Facility status notes revealed that as of May 3, 2023, R1 refused to eat and drink. On May 5, 2023, R1’s responsible party requested for R1 to be evaluated by a medical professional and R1 was then sent out for additional medical follow up. Medical records revealed that at this time, R1 was diagnosed with a closed fracture of left hip and received surgery to treat the fracture. Based on staff and outside source interviews conducted, review of records, including outside sources records, a preponderance of evidence exists to support the allegation neglect/lack of supervision resulted in R1 sustaining a fracture and sutures as a result of not following R1’s care plan. The allegation is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). The Department has determined this violation resulted in injuries to the resident in care.  An immediate Civil Penalty of $500.00 is charged and is noted on the LIC421IM.  At this time, per 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 Executive Director RIsa Jester, 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 Executive Director RIsa Jester , signature on this form confirms receipt of documents. Interview with multiple staff revealed R1 returned from the hospital with a rash sometime in May of 2023. Records collected corroborated R1 was admitted to the hospital in May of 2023 where R1 received extended care for an unrelated medical issue. Interview with staff revealed residents are monitored for incontinence care every 2 hours. It was also alleged that R1 was observed to have pest on their personal items. On June 6, 2023, LPA Strong conducted a facility inspection and did not observe any pests. Interview with multiple staff revealed they have not observed any pest. Interview with an outside source established that they have not seen any pest at the facility. On today’s date, LPAs conducted an additional facility inspection and did not observe any pests. The third allegation states that R1 did not receive assistance with dental care needs. Records collected revealed R1 was scheduled and attended multiple dental appointment in 2023. Interview with staff revealed facility schedules regular dental appointments for residents and will provide transportation to such appointment. Lastly, it was alleged R1 did not receive regular blood sugar monitoring. Interviews with staff revealed that R1 is diagnosed with diabetes but does not require continuous blood monitoring. Records collected corroborated that R1 is diagnosed with diabetes but does not have a diabetic diet or require monitoring. Medical records collected did not reveal any information to establish that facility was not providing adequate care for R1’s diabetic diagnosis. Based on a review of pertinent records and interviews, the preponderance of the evidence standard was not met to prove the allegations. An exit interview was conducted with Executive Director Risa Jester, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.