Incident investigation·May 13, 2025

On May 13, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management - Incident visit. LPA met with the administrator and explained the purpose of today's visit. On April 25, 2025, the facility reported an incident concerning to resident #1 (R1) and resident #2 (R2) had an unwitnessed fall in their apartment. The facility called 911 and upon arrival of the paramedics, they found unknown medications without a valid prescription in the room. The facility has been in communication with the Foster City Police Department regarding the unknown medications that were found in the room. During today' visit, LPA interviewed the administrator, the resident service director, R1 and R2, conducted a facility tour with the resident service director and collected documents. According to the administrator, R1 and R2 were admitted in September 2024 and both of them have sustained multiple falls since admission. R1 has had 6 falls within 18 days and R2 sustained 6 falls within 21 days. On 4/25/2025, R2 was sent to the hospital due to a fall resulting in a closed fracture of right hip. The administrator reported that the facility has found alcohol and unknown medications in their room. The administrator also stated that the facility has completed several change of conditions and reassessed R1 and R2 after the falls but they continued to fall until they hired a private one on one caregiver. Furthermore, the administrator stated that the facility has issued a 30-day eviction notice due to the falls and safety. According to the resident service director, the facility has reported the falls to the provider and the psychiatrist. They have spoken to R1 and R2 about the contributing factors to their falls and encouraged them to hire a private caregiver for fall prevention. LPA interviewed R1 and R2 and both of them are of aware of the multiple falls and the contributing factors. R2 stated that the one on one caregiver has helped significantly with preventing them from falling especially for R1. In addition, R2 expressed that the facility has issued a 30-day eviction notice and they are seeking for new placement. LPA explained the process of the eviction notice to R2. No deficiency is cited. This report is reviewed and discussed with the administrator; a copy is provided.