Incident investigation·April 27, 2026

LPA Serrano arrived at the facility to deliver a case management investigation report related to a fall experienced by Resident 1 (R1) on 10/20/2025 and concerns regarding the facility’s response, medical assessment practices, supervision, and change in condition procedures. LPA met with Executive Director Abraham Botello and discussed the purpose of the visit. R1 moved into the independent living area on 10/28/2020 and did not require assistance with daily activities at the time of admission. On 10/20/2025, R1 contacted the front desk and requested help after they fell inside their room. Staff 1 (S1) responded and helped R1 up from the floor. S1 stated that R1 reported hitting their head during the fall. S1 reported that R1 appeared to have no visible injuries and reportedly refused medical care. Staff 2 and Staff 3 also responded to the call but did not enter the room or assess R1 for injuries. The Department interviewed the Administrator, who stated they believed R1 had no fall history prior to the 10/20/2025 incident. The Department reviewed R1’s facility records and identified a total of nine falls dating back to January 2024 . All but one occurred in R1’s room and were unwitnessed. Three of these falls resulted in hospital transport for serious injuries, including hip injuries. Records also indicated R1 hit their head in at least two prior falls. Additional documentation showed multiple hospital transports for breathing issues and other medical conditions. The only Physician’s Report available was dated 10/1/2020 , with no updated assessments on file. The Department conducted a follow-up interview with the Administrator. The Administrator stated they had only been in their role for a few months and were unaware of R1’s fall history. The Department asked whether R1 had been re-evaluated given their repeated falls and clear changes in condition. The Administrator confirmed that no updated medical assessments existed. The Department advised the Administrator that based on the frequency of falls, injuries, and medical needs, R1 should have been considered for a higher level of care such as assisted living. The Administrator agreed. The Department’s review concluded that R1 had not been medically re-evaluated since 10/1/2020, despite multiple falls and significant medical concerns. The facility did not take steps to reduce R1’s fall risk or request a higher level of care. The Department reviewed the facility’s response to R1’s fall on 10/20/2025. S1 reported that R1 stated they hit their head. S2 and S3 responded but did not enter the room or assess R1. S1 1 claimed R1 refused medical treatment. S2 instructed S1 to monitor R1 every hour for any change in condition. The Administrator stated that while the facility has no written policy on suspected head injuries, staff are instructed to call 911 when a resident hits their head or is suspected of hitting their head. S3 confirmed this expectation. The Department interviewed R1. R1 stated they told S1 they hit their head hard and that their head and right side were hurting. R1 stated S1 did not assess them and that they did not refuse medical care. R1 stated they remained in their room for two days in pain until they contacted the front desk again. Facility records show that on 10/22/2025, S3 called 911 after R1 asked for help. The Department reviewed documentation and found no recorded hourly checks between 10/20/2025 and 10/22/2025, despite staff claiming these checks were performed. R1 also reported no staff checked on them during these dates. S3 confirmed that such monitoring should have been documented. Based on the information reviewed, the Department determined that the facility did not provide timely medical attention and did not conduct required monitoring after a reported head injury. The Department concluded that the facility failed to provide care and supervision, failed to observe and document changes in condition, and did not meet Title 22 RCFE requirements. Deficiencies were cited on LIC 809-D. An exit interview was conducted and a copy of this report along with the Licensee's Rights (LIC9058 03/22) was provided to Abraham Botello signature on this form confirms receipt of these documents.