Incident investigation·November 6, 2025

On 11-6-2025 at 10:15am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding an incident reported by facility on 9-4-2025. LPA met with lead caregiver Avia Singh and explained the purpose of the visit. Administrator Maria Almendrala was contacted by phone and made aware of LPA's visit and purpose. LPA spoke briefly with Administrator via phone, and conducted brief interview with staff2 (S2) LPA also reviewed facility file documentation including incident report dated 9-4-2025, caregiver schedule, care notes pertaining to resident1 (R1), physician's report and needs and service plan pertaining to R1. Based on interview and record review, it was revealed that on 9-1-2025 at approximately 5:00am, R1 contacted caregiver who arrived to find R1 sitting on his bed. R1 informed caregiver that he had fallen. Caregiver informed R1 9-1-1 would be called, however, R1 refused services stating he was not in pain. Caregiver asked R1 if he can stand, and R1 stated he was unable to stand. As a result, caregiver again informed R1 that 9-1-1 would be called. Caregiver called 9-1-1 at approximately 5:10am. According to care notes reviewed, it was revealed that on 9-11-2025, family member of R1 notified administrator that R1 will not be returning. Interview conducted revealed that Administrator was informed R1 went to a rehabilitation facility for 2 weeks after a hip surgery at the hospital. R1 was then discharged to another facility. Interviews and record reviews further revealed that R1 did not have a history of falls, but had previous medical issues regarding R1's hip. Interviews and record reviews revealed R1 did not require special supervision level, and two staff were on duty at time of fall. {Cont. on 809C} Based on today's case management, it is undetermined if R1's fall was the result of a Title 22 or health and safety code regulatory violation. As a result, no citation is issued. An exit interview was conducted with lead caregiver, and a copy of this report was provided.