complaint·August 18, 2025

(Continued from LIC9099 2 of 3) On the 1st of July 2023, R1 companion hours were decreased from 24 hours, 7 days a week, to 8:00 AM until 8:00 PM. Facility staff checked on R1 every two hours while they were in their room at night. R1 suffered an unwitnessed fall on July 6, 2023. During a routine check on R1, they were found on the floor in their room by a caregiver between 5:00 AM to 5:30 AM. The on-duty Med-Tech was called, and R1 was assessed for injuries. The Med-Tech immediately notified hospice, and a hospice nurse arrived at 6:30 AM to reassess R1. X-rays were conducted the same day (July 6, 2023), and initially, the report indicated there were no breaks or fractures. R1 was treated at the facility by hospice for pain management. A second X-ray report was sent on July 10, 2023, which revealed R1 had a fractured hip. R1 was then sent to the hospital for further evaluation at the request of Outside Source 1 (OS1). Facility staff were proactive in trying to mitigate the risk of falling and sustaining injury. Once it was determined that R1’s risk of falling had increased, R1 was placed in hospice and provided a companion. In addition, staff were conducting regular checks on R1 while they were in their room at night. It was alleged that neglect/lack of care and supervision resulted in a resident not getting timely medical attention. R1 was found on the floor in their room on July 6, 2023, between 5:00 AM and 5:30 AM. The on-duty Med-tech was immediately called to assess R1. R1 had cuts/abrasions on both elbows, but there were no head or other visible injuries. The Med-Tech immediately notified hospice, and a hospice nurse arrived at 6:30 AM to reassess R1. X-rays were conducted the same day, July 6, 2023, and initially, the report indicated there were no breaks or fractures. R1’s care was discussed amongst the hospice nurse and OS1, and it was decided R1 would remain at the facility and be treated by hospice for pain management. A second X-ray report was sent on July 10, 2023, which revealed R1 had a fractured hip. R1 was then sent to the hospital for further evaluation at the request of OS1. Interviews were conducted with 3 (Three) residents. The residents reported that they received adequate care and supervision from the staff and have not experienced or witnessed any neglect or lack of supervision. Interviews were conducted with outside sources, and they confirmed that they have observed staff providing attentive care and supervision to their loved ones and have no concerns about a lack of supervision or neglect. (Continued from LIC9099C 3 0f 3) During the visit, the resident’s living environment and interaction with the staff were observed. Staff were seen providing attentive care and supervision, ensuring the safety and well-being of residents. The environment was found to be free from hazards. A review of the resident's care plan, medical records, and incident reports for the past quarter showed that the resident received appropriate care and supervision. The records indicated that the resident's fall and resulting hip fracture were promptly addressed, with immediate medical attention provided. The facility's policies on care and supervision were reviewed and found to be comprehensive and in compliance with Title 22 and California Health and Safety regulations. The policies outline procedures for monitoring residents and preventing falls. The Department has investigated the above-mentioned allegations and based on observations, interviews, and records review. The Department has found that although the allegation may have occurred or be valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur; therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report and licensee rights (LIC 9058 03/22) was provided. Operations Specialist, Benjjie Doctoloero signature on this form confirms receipt of these rights.