Facility Evaluation Report

Licensing Program Analyst (LPA) Tena Herrera conducted a subsequent case management visit in response to an initial Case Management dated 4/14/25 following a Special Incident Report (SIR) that the department received explaining a fracture that Resident #1 (R1) sustained. LPA met with Maria Vasquez and explained the purpose for the visit.

On 4/11/25 the department received an SIR dated indicating the following: On 4/10/25 R1 was hospitalized after experiencing an unwitnessed fall, this fall caused resident to sustain a hematoma to the forehead, left wrist, friction burns and fracture.

On 4/14/25 LPA obtained copies of the following documents: R1's FACE Sheet, Appraisal Needs & Services Plan/IPP, Physician's Report, Medication List, and discharge paperwork from hospitalization dated 4/10/25.

From 4/14/25 - 8/1/25 Investigator D.Douglas, reviewed/investigated this case and it was revealed per the Incident Tracking Report that R1 experienced a total of 32 falls from January 2021 - April 2025 where R1 was either discovered on the floor/ground by staff members/witnesses and sustained a superficial injury as a result of almost falling down. It was also documented that R1 experienced altered consciousness following a fall and occasions where R1 had fallen twice in one day.Therefore, as a result of the information Investigator D.Douglas obtained during the course of the investigation, the allegation of Neglect/Lack of Care and Supervision is Substantiated at this time.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency issued today is documented on 809D. Exit interview held, a copy of the report and appeal rights were provided.