Incident investigation·August 12, 2025

08/12/2025 09:45 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Mendee Harrong. Today’s visit is regarding an incident that occurred on 08/06/2025 and was reported to licensing on 08/07/2025. It was reported that on 08/06/2025 at approximately 10:11 AM, Client 1 (C1) was using the bathroom. Staff 1 (S1) heard a loud thud in the bathroom and immediately went to check on C1, C1 was found on the floor. C1 was assessed, was conscious. C1 stated they were using the toilet, felt dizzy and fell to the floor. S1 observed C1 was bleeding on their lower right lip and chin. S1 immediately called Administrator who was already on their way to the facility. S1 assisted C1 up off the floor and helped stop the bleeding. C1 requested to go lay down on their bed. At 10:15 AM the administrator arrived at the facility and assessed C1’s injuries. C1 stated their jaw was hurting, they were feeling dizzy and didn’t have the strength to walk. At 10:35 AM administrator called 911. EMT's transported C1 to St. Elizabeth Emergency Room, Administrator accompanied C1. A CT scan was completed on C1’s head and face. Blood work and urine sample were collected. C1 was given a tetanus shot and fentanyl for pain. Chest x-ray was completed to check for pneumonia. X-ray results showed C1's left jaw was broken and their left ear was discharging blood. The ER doctor stitched C1’s chin and bottom lip, and ordered for C1 to be air lifted to UC Davis so a nose, mouth and throat specialist could examine C1 as St. Elizabeth does not have a specialist. At 4:36 PM C1 was airlifted to UC Davis. Continued on LIC809-C It was determined that when C1 had an unwitnessed fall in the restroom, staff responded immediately, assessed C1 for injury and rendered first aid, called the administrator. 911 was called and C1 was transported to the local ER. C1 was subsequently transported to UC Davis for further treatment. C1 was discharged from UC Davis and is now at home. LPA observed C1 in the facility using a walker ambulating independently with staff observing. In order to prevent this from occurring the facility will conduct a fall prevention training with all staff. Administrator will submit a copy of the facility’s fall prevention plan to LPA. LPA referred administrator to ​​​​​​​​​StopFalls Sacramento Coalition for additional resources in fall prevention. https://dhs.saccounty.gov/PUB/StopFallsSacramento/Pages/Stop-Falls-Sacramento-Coalition.aspx No deficiencies were issued as a result of the visit. A copy of the report was provided to the administrator