Complaint·December 18, 2025

Regarding the allegation, “Facility staff did not notify authorized representatives of falls”; it is the concern of the Reporting Party (RP) that Resident 1 (R1) has had three falls in the facility with the last one being on November 12, 2025, and staff did not notify R1’s authorized representatives of all three falls. A review of R1’s Identification and Emergency Information (LIC601) signed and dated 09/19/2024 revealed that Individual #1 (I1) is listed as their responsible person and Individual #2 (I2) as their person(s) responsible for financial affairs, payments for care, legal guardian if any. A review of R1’s Family Communication Form also lists I1 as R1’s primary contact/emergency contact #1 and I2 as R1’S primary contact/emergency contact #2. Interview with the Executive Director Christian Castillo revealed that I1 would be the person that needs to be contacted to notify of falls and the MedTech (MT) would usually be the one to notify them. Interview with one randomly selected MT revealed that based on R1’s file on their electronic medical record system I1 would be the person they need to contact to notify if R1 sustained a fall as they are listed as their Power of Attorney (POA). However, Interview conducted with I1 revealed that they were never notified by the facility that R1 had sustained a fall, were notified by R1 after being at the hospital for 8 hours and denied being R1’s POA. They further revealed that I2 is four hours away from R1 compared to them being only an hour away and they had already previously discussed with staff after prior falls that they should be the one to be notified. Furthermore, a review of an Unusual Incident/Injury report (LIC624) submitted to Community Care Licensing (CCL) on 11/18/2025, revealed that on 11/13/2025 staff responded to a pendant call and observed R1 on the floor, R1 was transported to the hospital and I2 was contacted. LIC624 does not indicate if I1 was contacted at all, however I1 denies they were contacted. Record review revealed that the facility does not have any POA records for R1, however has I1 listed as their POA in their electronic medical record system. Interview with Director of Health and Wellness Gina Taylor revealed that R1 was admitted to the facility as independent and their own responsible person, however they did confirm that even in these circumstances residents have emergency contacts listed as to whom staff should be notified of incidents. Based on the information gathered there is sufficient evidence to support the allegation and that a violation occurred; therefore, the above allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D).Exit interview conducted, appeal rights discussed, and a copy of this report issued .