complaint·July 22, 2025

During interview on 05/15/2025, resident R1 stated that R1’s last fall occurred in R1’s bedroom. R1 stated that during the fall, the staff were in the bedrooms of other residents or in the common area. R1 stated the staff provide R1 with enough supervision. R1 stated staff are always with R1 and walk R1 to the eating area and restroom, including while R1 showers. During visit on 07/22/2025, LPA Marrufo interviewed staff S1-S4. During interviews, S1 and S3 stated that R1 experienced a fall in April 2025. S1 and S3 stated that R1 was sitting in the living room while S1 and S3 were in the bedroom of a resident who required cleaning and changing assistance of two staff. S1 and S3 stated R1 had an alarm attached to R1’s walker and S1 and S3 regularly reminded R1 to use the alarm if R1 needs assistance with standing or ambulating. S3 stated R1’s walker has a sign reminding R1 to use the alarm for assistance. S1 and S3 stated R1 stood up without using the alarm and S1 witnessed R1 fall. S1 was able to immediately assist R1 after the fall. During visit on 07/22/2025, LPA Marrufo observed a sign on a food tray in the living room near a chair. The food tray had a sign taped to it that said, “Call for Help! Before getting up.” LPA Marrufo observed R1’s walker. LPA Marrufo observed that R1’s walker also has a sign attached to it that says, “Call for Help! Before getting up.” LPA Marrufo observed R1’s bedroom has a sign that says “Call don’t fall” and has a photograph of an alarm button. During interview on 05/15/2025, R1 stated to have an alarm installed on R1’s bedroom floor. R1 stated to also have an emergency pendant, which LPA Marrufo observed during interview. R1 stated staff respond to the pendant alarm within two minutes, including when R1 pushes the pendant alarm at night. During interviews on 07/22/2025, S1-S4 stated that they respond within a minute to R1’s emergency pendant alarm. Page 2 of 3. During visit on 07/22/2025, LPA Marrufo obtained a copy of R1’s Morning Diaper Change Log for April and May 2025. The Morning Diaper Change Logs record staff assisting R1 with diaper changes at least once per day in April and May 2025, with some days indicating staff changed R1’s diapers up to four times in a day. During interview on 05/15/2025, R1 stated staff change R1’s diapers as often as R1 wants. R1 stated staff have never left R1 in soiled diapers for an extended period. During interviews on 07/22/2025, S1 and S3 stated staff change R1’s diapers at least every two hours. S2 and S4 stated they change R1’s diapers three times at night. During visit on 07/22/2025, LPA Marrufo obtained a copy of R1’s Shower/Bath Log from April and May 2025. R1’s Shower/Bath Logs indicate that in April 2025, R1 received 4 showers and 26 sponge baths and in May 2025, R1 received 9 showers and 21 sponge baths. During interview on 05/15/2025, R1 stated staff provide showers to R1 once every other day. R1 stated staff sometimes provide R1 with a sponge bath. R1 stated staff recently gave R1 a sponge bath because R1 was not able to take a shower. During interviews on 07/22/2025, S1 and S3 stated staff give R1 showers 3 times a week and sponge baths 4 times a week. S2 and S4 stated staff shower R1 every other day. Based on information from interviews conducted with staff and residents, and records reviewed, although the allegations listed above 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 allegations are unsubstantiated. No Deficiencies were cited under California Code of Regulations Title 22. This report was reviewed with Justin and Irish Ladwig and a copy of this report was provided. Page 3 of 3. END REPORT.