Incident investigation·September 23, 2025

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced to conduct a case management visit. LPA met with Administrator Wendy Cornejo. On 8/29/25 CCL received an Incident Report from facility indicating that on 8/20/25 staff discovered R1 had missed 4 days of prescribed Pravastatin Sodium ( deficiency cited, see 809D ). Also on 8/20/25 R1 was taken to the emergency room (ER) due to feeling weakness on their right side. R1 was diagnosed with a UTI and was prescribed antibiotics. UTI not caused by medication error. R1 returned to the community 8/22/25. On 9/15/25 CCL received an Incident Report from facility indicating that on 9/8/25 staff was assisting R2 out of her apartment when R2 lost her balance and fell. R2 subsequently reported having back pian. R2 seen at the hospital where they diagnosed them with a neck fracture. R2 returned to the community the same day. LPA reviewed R2 charting notes. Fall was recorded on Safely You video. LPA reviewed video. LPA observed staff (S1) to place walker out of reach of resident and used it to prop open the door to the apartment . R2 fell to the floor and S1 left resident on floor to go and get help. Administrator reviewed with S1 best practices are to remain with resident and radio/call for assistance as well as how to properly use postural support for ambulation. Resident R2 placed on 72 hr monitoring. R2 was scheduled to have a follow up appointment to assess injury, but had a subsequent fall and returned to the hospital on 9/15/25. LPA reviewed assessment and physician's report for R2. Physicians order on file for walker. Assessment indicates extensive hands on assistance with ambulation and transferring needed ( deficiency cited, see 809D ) . Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.