Complaint·December 17, 2025

Based on facility notes, R1 did not have any falls, injuries, or redness until 01/18/2025. On 01/18/2025, it notes thigh is swelling and looked weightless after moving while changing. Based on staff statements and facility documents, R1 was last seen in normal physical condition on 01/18/2025, at around 9am, and was found by S1 with a left thigh injury between 1100-1150pm. Staff denied R1 falling out of bed or having an accident while using the Hoyer lift. Staff denied R1 hitting his/her leg against the bed or another resident assaulting R1. Staff denied assaulting R1 and staff did not know how R1 sustained the injury. Based on the findings, R1 sustained an unexplained femur fracture while in care at the facility. At the time of the complaint inspection on 12/17/2025 licensee was informed that the incident is currently under review and a future civil penalty may apply based on Health and Safety Code §1569.49. Based on interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC-9099D. An immediate $500.00 was assessed today due to R1 sustaining unexplained injury while in care. Report is reviewed and a copy of the report and Appeal Rights is provided.