Follow-up on corrections·February 12, 2026

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced Case Management visit in conjunction with Complaint #29-AS-20250514091509. The LPA arrived at 9:57AM and met with Executive Director (ED) Kellie Smith. Entrance interview conducted. On 09/10/2025, the Complaint investigation was referred to Community Care Licensing Division’s (CCLD) Program Clinical Consultant (PCC) and assigned to Lorena Kho. PCC Kho reviewed documents including facility files, hospice records, and hospital records. During today’s visit, LPA Huynh and the ED conducted a physical plant tour at 10:03AM and no immediate concerns were observed. The following was revealed during the Complaint investigation: Between 05/05/2025 and 05/12/2025, Resident #1 (R1) sustained three (3) falls resulting in wrist fractures, a skin laceration, and significant physical pain. On the morning of 05/06/2025, R1 informed their Hospice nurse of an unwitnessed fall that occurred the evening of 05/05/2025. According to Hospice notes, facility staff denied the fall due to the absence of documentation. Later that same day, during a care plan meeting with R1’s family, the facility disclosed an unwitnessed fall that caused bruising and swelling to R1’s right shoulder, though no specific date or time was provided. The facility did not provide any additional information or documentation regarding the care plan meeting. Report Continued on LIC 809-C On 05/07/2025, R1 sustained a second fall in the dining room, landing in a seated position on the floor while attempting to reach for a snack. On 05/12/2025, R1 was left unattended near a fireplace and was found on the floor with a skin laceration. Staff interviews revealed that R1 had been left unsupervised while staff attended to another resident, and R1 was later discovered by a staff passing by. R1 began reporting pain and limited mobility in their arm on 05/06/2025. The facility notified Hospice who recommended as needed (PRN) medications, increased dosages, and provided new medication orders. In the following days, R1 continued to report severe pain and was unable to move their arm. Facility staff and the Hospice nurse observed extensive bruising and swelling extending from R1’s right shoulder to the right arm and upper right chest. Staff documentation included observations such as: “moaning in pain and [their] arm is extremely swollen and bruised,” “redness and swelling continues to worsen,” and “right hand is so swollen and [their] arm just hanging down [their] recliner.” The Facility Assessment Summary documented R1’s last assessment on 02/05/2025 with an effective date of 05/01/2025. The Assessment indicated R1 required standby assistance and cueing for transfers and showering, did not require assistance with repositioning, and was able to ambulate to the dining room and participate in activities without assistance. R1 was identified as a high fall risk and at high risk for fractures due to osteopenia. The Assessment instructed staff to “provide personalized interventions, per fall management protocol,” but did not specify active transfer or ambulation assistance or other safety measures to prevent falls or fractures. The facility did not complete an updated assessment or implement additional safety interventions following R1’s initial falls, further increasing R1’s risk for subsequent falls and injury. Report Continued on LIC 809-C On 05/25/2025 CCLD received an Incident Report stating that R1 experienced a “slip/fall” on 05/12/2025 resulting in a skin laceration and was hospitalized on 05/13/2025 when fractures were discovered. The Incident Report also referenced an unwitnessed fall on 05/06/2025 “which didn’t result in any serious injuries except slight complaints of discomfort… noted by light bruise on the clavicle.” However, the report did not disclose R1’s second fall on 05/07/2025. Interviews with R1’s family revealed that the facility did not communicate or disclose the seriousness of R1’s condition, aside from receiving notification of the first and last falls. Based on interviews and record review, the facility failed to provide adequate care and supervision to R1, resulting in fractures of the distal radius and distal ulna with soft tissue swelling, as well as a skin laceration. The facility also failed to provide timely and adequate notification to R1’s family and did not submit required notification to CCLD within seven (7) days of the occurrences, as required by reporting regulations. An immediate civil penalty in the amount of $500 was assessed today (Refer to LIC421M). The ED was informed that additional civil penalties may be assessed based on Health and Safety code Section 1569.49. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiencies were cited (Refer to 809-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.