Complaint·January 9, 2024

(Continued from 9099) There is no indication the door chime was not working. Multiple staff stated the patio door alarm was operational and loud on the day of the incident. At approximately 1900 hours R1’s fall pad alarm went off and an alert was immediately sent to the cell phones for employees working that shift: S2, Staff (S3), Staff (S4), Staff (S5) and Staff (S6). S1 stated S3 was responsible for monitoring the living room area and responding to R1’s fall pad alarm. S1 stated video recordings showed S3 standing inside the living room and failed to respond to the alarm notification. S3 remained in the same position until S3 heard R1 banging on the door at approximately 1932 hours. R1 was left outside unsupervised for approximately one and a half hours. S6 stated R1 was cold to the touch indicating R1 had been outside for an extended period of time. R1 was a known fall risk and required additional supervision. R1 was not permitted to be in the patio area alone due to being a fall risk. R1 was transported to the hospital by ambulance and diagnosed with a hip fracture requiring surgery and hospitalization. Based on the Department’s observations, interviews conducted and records reviewed the preponderance of evidence standard has been met, therefore the allegation that neglect by the facility resulted in resident’s injury is substantiated. California Code of Regulations, Health and Safety Code (1569.269 (a) (6), are being cited on the attached LIC 9099D. (Continued on 9099-C) (Continued from 9099-C) An immediate civil penalty is being assessed today in the amount of $500 for a violation that resulted in the sickness or injury of a resident in care. The licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Additionally, it is alleged that the facility’s lighting in the patio area where R1 fell was not working properly. Facility records indicate that staff were aware of the lighting not being fully functional as maintenance requests were made for repairs on “End of Shift Reports” dated 9/13/2022, 1/30/2023 and 2/19/2023. Based on the Department’s observations, interviews conducted, and records reviewed found the facility’s poor lighting in the patio area contributed to R1’s fall and injury and therefore the allegation that the facility was in disrepair is substantiated. California Code of Regulations, (Title 22, Division 6, Chapter 8, Article 5 Physical Environments and Accommodations). Appeal rights given.