It was reported that over a period of two hours R1’s responsible party (RP) called the facility seven different times to notify staff that R1 required assistance but staff did not answer the phone. RP determined this due to R1 having a video camera in their room which the RP was monitoring.

All staff who were interviewed stated they were not aware that staff did not answer the phone when the RP was trying to speak with the facility. Staff stated that sometimes the phone will only ring once but staff return calls to whomever leaves a voice mail.

Executive Director stated When the resident’s family called the facility there was no answer and it took a couple of hours until staff returned the call. ED told staff if they are busy and cannot answer they are to return the call as soon as possible. ED stated that staff spoke with the RP at 5:00 AM.

This allegation is substantiated.

Facility staff do not respond to residents’ calls in a timely manner. - SUBSTANTIATED

It was reported that on 05/08/2026 08:00 PM R1’s family member saw staff (via video camera in the resident’s room) bring R1 into their room and place R1 in their recliner with their feet up, and turn the television on loud. Staff walked out of the room and no staff came to check on R1 for nine hours, which left R1 struggling and trying to get out of the recliner. R1 called for help, and staff did not come and help R1.

Witness interviews confirmed that R1 was placed in a recliner in their room, was unable to get out of the recliner for hours.

During staff interviews it was learned that R1 had a call light pendant but never used it.

Executive Director stated A staff member thought R1 could get out of the chair in their room on their own because this staff saw R1 getting out of the chair in the common area which has a different type of recliner. ED told staff that they are not to put the resident’s feet up because the chairs don’t have a lever to lower them.

It was determined that R1 was left in the recliner in their room with their feet up, calling for help and unable to get out of the chair. This allegation is substantiated.

It was reported that staff left Resident 1 (R1) in their room and did not check on R1 for nine hours, during which time R1 could not use the restroom.

LPA reviewed LIC602 Physicians Report for R1 which states that R1 is independent with toileting. Needs and Services Plan states that R1 is standby assist for toileting due to fall risk.

Witness interviews confirmed that R1 was placed in a recliner in their room, was unable to get out of the recliner for hours.

During staff interviews it was learned that R1 is mostly independent with toileting but does require reminders and assistance to get to the bathroom.

Executive Director stated R1 knew when they had to toilet, staff would remind R1 but R1 typically went to the toilet every 20 minutes and staff would walk with R1 because they were unsteady sometimes. A staff member thought R1 could get out of the chair in their room on their own because this staff saw R1 getting out of the chair in the common area which has a different type of recliner.

It was determined that R1 was left in the recliner in their room with their feet up, calling for help and unable to get out of the chair which resulted in R1 not being toileted. This allegation is substantiated,

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to Executive Director Irene Davis

It was reported that Resident 1 (R1) experienced multiple falls which resulted in injuries.

LPA reviewed the following photographs of R1: R1 with a lateral incisor to the right of the central incisor. A separate photograph shows the lateral incisor to be diminished to a small stub which is usually consistent with cosmetic dentistry preparation for a crown or veneer. Photograph of R1 shows R1 smiling with bottom teeth present. Photograph of left foot with dry skin, fungus, dried blood on large left toenail. LPA did not receive any photographs of bruising to R1.

LPA reviewed the following incident reports: 04/19/2026 R1 was getting up off the couch in the common area and slid to the floor, no injuries reported. 04/21/2026 Staff heard a noise from R1’s room, upon response found R1 on the floor, assessed for injury none found. 04/25/2026 R1 slapped another resident on their arms and slapped a staff member. No injuries noted. 04/26/2026 EMS was called to assess R1 for shoulder injury per family’s request. EMS assessed and did not transport R1. 05/09/2026 R1 was found on the floor of another resident’s room. R1 stated they did not fall but put themselves on the floor. Staff assessed R1 for injuries and found none. 05/22/2026 R1 had a witnessed fall in the common area during which R1 struck their head. EMS was called and transported R1 to hospital where R1 was treated for a head injury.

LPA reviewed LIC602 Physician’s Report dated 04/15/2026 which states under history of skin breakdown that R1 picks at their scabs.

During staff interviews it was learned that R1 spent the majority of their time in the common area and was usually in line of sight for staff. All staff stated that R1 is a habitual “picker” which resulted in the loss of the cap that was on R1’s lateral incisor. Staff witnessed R1 remove that cap from their tooth while eating and handed it to staff.

Executive Director stated R1 had a scraped knee as a result of a fall but an MRI and x-ray showed no injury.

It was determined that R1 experienced three documented falls while living at the facility. R1 was assessed for injury after each fall, 1 of 3 falls resulted in injury to R1 when they struck their head in the common area and were transported via EMS to hospital for treatment. This allegation is unsubstantiated.

Continued on LIC9099-C

It was reported that R1’s family was only notified twice that R1 had received injuries throughout the entire time that R1 lived at the facility.

LPA reviewed admission agreement for R1 dated 04/17/2026 which has R1’s spouse as the legal responsible person (RP) for R1. LPA reviewed an email that was sent to the Executive Director on 05/12/2026 which includes a request for a specific family member to be notified of all incidents and changes related to R1.

LPA reviewed a total of six incident reports for R1 that were submitted from 04/19/2026 through 05/21/2026. 5 of 6 incident reports indicate no injuries resulted. RP was notified about 4 of the six incidents. One incident report includes injury to R1, RP was notified of this incident.

5 of 7 staff stated the RP was informed of falls and other incidents while R1 lived at the facility. 2 of 7 staff did not know if the RP was notified.

Executive Director stated the RP for R1 is their spouse who requested that we call another family member.

It was determined that the RP for R1 remained their spouse who was informed of all incidents prior to 05/12/2026 when staff were notified to call another family member. Five incidents occurred prior to 05/12/2026 and one incident occurred after this date, the alternate family member was informed of this incident. This allegation is unsubstantiated

Continued on LIC9099-C

Upon review, LPA could not locate any documentation or indication that R1 experienced a change in medical condition during the time they lived at the facility.

All staff that were interviewed stated that R1 had not had a change in medical condition during the time they lived at the facility.

Executive Director stated that R1 was getting used to living at the facility and was becoming more comfortable with their surroundings right before they moved out of the facility. If anything, their condition had improved.

It was determined that R1 did not have a change in medical condition during the time they lived at the facility. This allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of of evidence to prove that the alleged violation occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to executive director Irene Davis.