Incident investigation·March 11, 2026

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent Case Management – Incident visit for the purpose of following up on a self-reported incident that occurred on 09/10/2025. Upon arrival, LPA was greeted by facility staff. Administrator was contacted via telephone and was read the report over the telephone. Entrance interview conducted. On 09/12/2025, an Unusual Incident/Injury Report was received at the Woodland Hills North Regional Office related to Resident #1 (R1). Written report indicates that on 09/10/2025 during the dinner hour, R1 had been seated at the dining table. Staff had left the area to assist other residents when R1 stood up unassisted, resulting in a fall. R1 was sent to the hospital, where it was determined R1 had sustained a fracture as a result of their fall. Additionally, R1 had a sepsis infection and passed away on 09/11/2025 while hospitalized. During an initial visit conducted on 09/17/2025, LPA interviewed Administrator related to the incident and LPA, along with Administrator, toured the pertinent areas of the facility at 11:08AM. No immediate health and safety hazards were identified during that visit. LPA also reviewed R1's file and obtained copies of pertinent documents. A copy of R1's death certificate was not available at the time of the visit. Administrator was informed that the incident was referred to Community Care Licensing Division’s Investigations Branch (IB) and that either the LPA or an IB investigator would follow up on the self-reported incident. IB Investigator Heidy Bendana obtained and reviewed copies of relevant documents, including but not limited to R1’s facility and hospital records, 911 call and incident report. Investigator Bendana conducted interviews with Administrator, facility staff, residents, and other relevant parties on the following dates:10/06/2025, Report Continued on LIC 809-C 11/21/2025, and 01/13/2026. LPA Dulek then reviewed all information obtained. The following was then determined: Interview revealed that on 09/10/2025, there were two (2) staff working at the facility with four (4) residents in care. Residents were just finishing up dinner when one Staff #1 (S1) took Resident #2 (R2) to the restroom. Resident #3 (R3) then expressed an urgent need to use the restroom, so Staff #2 (S2) took R3 to use the restroom, leaving R1 and Resident #4 (R4) at the table with no direct supervision. Before leaving the table, S2 told R1 to remain seated. Record review revealed that R1 ambulated using a walker, “can walk with one person support,” and R1’s appraisal needs and services indicated R1 was a fall risk and had an unsteady gait. Interview with Administrator confirmed R1 was a fall risk. Additionally, R1’s appraisal needs and service indicated R1 was able to follow directions but had “episodes of forgetfulness and intermittent confusion.” Incident report indicated that while both staff were away from the table assisting R2 and R3 with toileting, R1 fell when attempting to get up and/or walk unassisted. R4 yelled for staff assistance and reported the fall to care staff. S2 returned to the dining room and found R1 on the floor, lying on their side. R1 complained of left leg pain. S2 assisted R1 off the floor and into the dining room chair, called the Administrator and 9-1-1. Emergency personnel responded and transported R1 to the hospital. X-ray results revealed R1 sustained a left displaced femoral neck fracture as a result of the fall. R1’s records show R1 was a fall risk and had intermittent confusion but was left seated at the table with no direct supervision, which resulted in R1 falling and sustaining a fracture. Hospital documents indicate femoral fracture was complicated by severe encephalopathy, severe acidemia, and severely elevated lactate. R1 was admitted to the Intensive Care Unit (ICU) for additional monitoring. R1 passed away on 09/11/2025. Cause of death was listed as arteriosclerotic cardiovascular disease. Other significant condition contributing to the death but not resulting in the underlying cause was left hip fracture and unspecified dementia. While hospital records did indicate R1 had a urinary tract infection (UTI) at the time of their hospitalization, all parties interviewed indicated R1 showed no signs or symptoms of UTI while at the facility. Additionally, R1 did not have a fever, chills, abdominal or back pain upon admission to the hospital. Facility staff stated in the days leading up to the fall, R1 did not express any pain and was eating and drinking as normal. Staff did not observe any change of condition, therefore did not obtain medical attention prior to the fall. On 09/10/2025, when R1 fell, staff reported to the Administrator and called 9-1-1 timely. R1 did pass away in the hospital the day after R1 fell in the facility, however, R1’s cause of death was not directly attributed to R1’s fall while at the facility nor did the investigation reveal evidence to substantiate that the facility did not obtain timely medical attention related to R1’s UTI diagnosis. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 809-D.) A $500 Immediate Civil Penalty was assessed. Administrator was informed that additional civil penalties might be assessed based on health and safety code 1569.49(f). Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.