Incident investigation·August 18, 2025

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management Incident inspection at the facility today. The LPA met with Licensee representative Jovilito Gagarin and explained the reason for the inspection. On 07/31/2025, Community Care Licensing (CCL) received an Unusual Incident/Injury Report (LIC 624) pertaining to Resident #1 (R1). The report stated that on 07/27/2025, about 4 pm, R1 while seated at the couch at the living room attempted to get up and fell on the floor on the right side of his body hitting the floor. A cut and bruise on the right elbow had resulted from that accident. Two staff (S1, S2) observed the incident. It was further reported that R1's responsible person was contacted the same day and notified of the incident. On, 07/29/25, R1's responsible party took R1 to the hospital and at the time of the report R1 was still at the hospital. On 08/01/25, LPA Cortez conducted an interview with Licensee representative, Jovilito Gagarin telephonically , who stated they were informed from R1's responsible person that R1 had sustained a fracture. Additionally, Mr. Gagarin stated that R1 is a fall risk, and the week before R1 fell at the facility they had fallen at their responsible person home and believe the fracture was sustained from that fall. During today's visit, the LPA conducted interviews with Licensee representative Jovilito Gagarin, two (2) staff, one (1) resident, and R1's responsible person (telephonically). The report will continue on LIC809-C, 2nd page. Mr. Gagarin revealed that when they were informed of the incident, he had asked staff it it was serious because if it was they would have to call 911 and staff had informed them it was not so serious. Additionally, he revealed that after informing R1's responsible person (RP) about the incident, they asked the RP if they wanted them to call 911 and the RP asked them if it was serious and they replied no and the RP notified them they would visit R1 the following day. Lastly, Mr. Gagarin revealed that Staff accessed R1's body by pressing it and R1 did not screamed therefore they were not in excruciating pain. S1 and S2 revealed that they did not witness R1's fall as one was in the kitchen and the other in the laundry room and R1 was sleeping in one of the recliners in the living room, they heard the fall and immediately went to the resident. After R1's fall, R1 complained about pain the same day and the following day and S1 applied warm water with a rag on his body. S1 revealed they notified their boss about the incident and it's up to the boss to determine if 911 is called or not. Both staff revealed that R1 had a prior fall just days before at R1's RP's home and believe R1 sustained a fracture then. A telephonic interview with R1's RP revealed that they were notified of R1's fall and was told that everything was under control. However when they visited on 7/28, R1 was passed out and could not wake up, on 7/29 R1 had a scheduled doctor's appointment and the RP and staff could not get R1 up and were not able to get R1 to their doctor's appointment. RP notice something was wrong and R1 could not put weight on their leg, and was not able to walk. Prior to the fall R1 was able to walk short distances with their walker. Lastly, the RP revealed that they were never asked if staff needed to call 911, and that they were only told that an assessment had been done. They did not know the severity of the incident until Wednesday when they took R1 to the Emergency Room and was notified that R1 had a broken hip. RP also revealed that R1 had sustained two falls at their home a week prior to R1's fall at the facility and would fall once to twice a week at their home and believes the facility provides adequate care for R1. The investigation revealed that on 7/27/25, R1 sustained a fall for which the facility staff did not obtain medical care, and on 07/29/2025, when R1's RP took R1 to the emergency room R1 was diagnosed with a broken hip. Based on the information obtained the Department found sufficient evidence to support that staff did not seek medical assistance for R1 in a timely manner. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 809-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.