Facility Evaluation Report

Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent unannounced case management visit in regards to a Serious Incident Report (SIR) received regarding Client #1 (C1) who sustained a fall and fracture on 8/28/2025. LPA met with administrator Jourdan Sanvictores and explained the purpose of the visit.

Per interview with Staff #1 (S1) and the SIR, C1 had been sitting on the edge of their bed when they had attempted to dress themselves, which caused them to fall and fracture their leg. C1 has been hospitalized and is currently in a Skilled Nursing Facility (SNF) since the incident to recover from the fracture.

Investigations Branch (IB) investigator Dennis Douglas investigated the above allegation, and in conversations with the family of C1 and the East Los Angeles Regional Center (ELARC), there was no evidence to suggest that the facility was responsible or at fault for C1's fall in the facility. Evidence suggests that C1 had intentionally threw themselves on the ground during the incident which caused the injury.

Based on all the information obtained during the investigation, the allegation of Neglect/Lack of

Care and Supervision as a result of C1 sustaining a significant injury is Unsubstantiated .

No deficiencies were observed during the visit. Exit interview held and a copy of the report was provided.