Follow-up·February 10, 2026

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct a case management related to the recent cluster of falls. LPA met with administrator Ryan Hust, to explain the purpose of the visit. Covenant Living of Turlock is a 377 bed facility where 167 of the beds have clients in a condition of being provided care. LPA toured several rooms and apartments of the facility, asked for SI reports related to falls for the past 2 weeks, asked for a copy of Plan of OP selections related to employee training including any specific related issue to falls including reporting requirements, and Shift schedules for a period of days. The toured locations of the falls for the past two weeks(aspen, sequoia, redwood), LPA identified no environmental risks for increased falls (torn rugs/trip hazards, unsecured bannisters/grab bars). LPA notes the Plan of Op was last updated in 2015, and is requesting any updates of the past 11 years be sent along in a revised plan of OP to the LPA's email by March 10th 2026. (noel.wolfpetersen@dss.ca.gov) . Per the facilities Policy training on Medical Emergencies, "the community summons 911 when the resident exhibits signs and symptoms of distress and/or emergency condition: ...to include fall with deformity, severe pain or head injury...". Does not designate seperate policy for witnessed or unwitnessed falls, nor situations where behavioral expression or pathology prevents an expression of pain. 3 of 5 falls in SI reports from the past 6 weeks included a phonecall to 911, responsible party, and a physician. the remaining 2 of 5 falls in SI reports from the past 6 weeks fell outside of the plan of op's stated reporting criteria, asserted to have been determined by the facilities reporting parties. One SI report of these two included bruising on the hands and knees. One client of these two was inclined to be interviewed, and denied feeling as though there was a shortfall in the care and supervision by the staff related to the fall. Continued on C-Page Per administrator melina Nunez, Employees are trained about the fall policy several times in a year. Per staff(sequoia), It occurs about once or twice a year, three Staff Interviewed(sequoia) were somewhat able to review the fall policy and indicated the training leaned heavier on reporting requirements rather than the approach to the client. LPA's review of the shift schedules for several affected areas (sequoia, aspen, redwood) in the given times indicate that the facility was fully staffed at the times of the falls. Per adminstrator Ryan Hust, the facility has multiple redundant systems that are operational to alert staff in the event of a fall: Emergency pull cords in the public bathrooms, and emergency pendants are equipped to the residents, a nurses phone number given to the residents, and staff that move through the buildings with regular frequency (3+ times a day) and are able to respond to cries for help. Fall reporting is attended to in a verbal pass down between shifts and a client file, after a fall 72 hour report checklists are given the staff to assess the client in more detail, updates are forwarded to managers if the reporting staff identify any kind of risk. The LPA's concerns regarding the facilities fall prevention policies are satisfied at this time. LPA gave guideance to conduct a updated policy training for Medical Emergencices, soon and at least once a year, to include how to identify risks to the onboarding clients including falls, to understand appropriate 911 intervention approaches for witnessed and unwitnessed falls, the unique supervision and care concerns of the clients with fall risk who also have a dementia or are otherwise unable to report pain verbally, as well as what situations where changes in a clients welfare would trigger a LIC 624 notification of a significant incident to licensing. LPA gave additional guidance to observe a general maxim if a fall is unwitnessed, call for emergency send out and allow any client refusal/deteriminations of medical necessity to play out with the ambulance, and document as much of the process as possible. No citations were issued. a copy of the report was read and given to the administrator. exit interview was conducted.