Complaint·July 10, 2025

In addition, staff interviewed had conflicting information on whether R1 was a fall risk or not. Facility staff were unaware of R1's injuries and did not document or notice any changes in condition nor how the injury could have been sustained. Based on medical records, on 10/13/24, R1 was transported to the hospital and three x-ray views of R1's left hip did not show any fracture at the time. Further evaluation with cross-sectional imagining was recommended and conducted on 10/16/24 where a computed tomography (CT) scan was conduct of his/her left hip for a possible fall. Medical documentation indicated that the CT scan showed that R1 had an acute non-displaced fracture through the base of the left superior pubic ramus and through the mid left inferior pubic ramus. Based on the investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Failure to correct said deficiencies may result in additional civil penalties. AN IMMEDIATE CIVIL PENALTY OF $500.00 WAS ASSESSED TODAY: $500 FOR THE VIOLATION AS R1 SUSTAINED UNEXPLAINED FRACTURE WHILE IN CARE. A repeat civil penalty of $500 was issued today due to the same violation being cited on 5/27/25. Due to immediate civil penatly of $500 being cited and repeat civil penalty of $500 being cited, total civil penalty being issued today is $1,000 THE INTERIM EXECUTIVE DIRECTOR WAS INFORMED THAT AN ADDITIONAL CIVIL PENALTY IS STILL BEING DETERMINED AND MIGHT BE ASSESSED BASED ON HEALTH AND SAFETY CODE §1569.49. Report is reviewed with the Interim Executive Director and a copy is provided with appeal rights. Regarding the allegation, facility staff are not cleaning resident's room, according to the reporting party, on 10/13/24, it was observed that R1's room was filthy, with soiled bed linens, old, soiled clothing, and urine pads on the floor. During the investigation, LPA toured the facility and observed a random sample of eight resident rooms including R1's room. Based on observations, rooms toured were observed to be clean, odor-free, and with clean bed linens. During the visit, LPA was notified that R1 was no longer a resident at the facility. According to staff interviewed, there are two housekeepers on shift in the AM and two housekeepers in the PM. Housekeepers are deep cleaning rooms every week, taking out trash from resident's room per shift and doing laundry as needed. In addition, staff interviewed indicated that every shift change, caregivers will check each resident rooms to make beds and collect trash at the beginning and at the end of each shift. Regarding the allegation, facility staff did not communicate with authorized representative(s) on resident changes in health condition, according to the reporting party, the facility staff did not know how or when R1 suffered a fracture and did not notify R1's authorized representative of any injuries or changes in condition. During the investigation, staff were interviewed and R1's charting notes were reviewed. Based on charting notes, there was no notes that indicated R1 had a fall or a change of condition. According to staff interviewed, they were unaware why R1 was sent to the hospital on 10/13/24 and indicated they did not see or here about R1 having a fall before or on 10/13/24. Additionally staff interviewed also indicated that they did not observe any changes in R1's condition or R1 complaining of pain prior to being sent to the hospital. Based on interviews conducted, interviews conducted and documents reviewed, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed with Interim Executive Director and a copy is provided.