Facility Evaluation Report

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced case management visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by staff and explained the purpose of the visit.

On June 6, 2025, the Orange County Regional Office received an incident report regarding unwitnessed falls involving Resident 1 (R1) resulting in a closed fracture. The investigation determined the following:

R1 was admitted to the facility on April 30, 2025, and was identified as a high fall risk based on the Preplacement Appraisal and Morse Fall Scale completed on April 28, 2025, by the facility staff. R1 sustained an initial unwitnessed fall on May 26,2025 and a secondary fall on May 30, 2025 per incident reports submitted to the Department. On May 26, 2025, at approximately 1:10 p.m., R1 sustained an unwitnessed fall in the common television room area of the memory care unit. R1 was found on the floor complaining of left ankle pain and was transported to the hospital for evaluation. R1 was diagnosed with a contusion of the lower leg and discharged back to the facility the same day. Hospital discharge instructions on May 26, 2025, directed the facility to ensure R1 was seen by their primary care physician (PCP) within three days. Interview with R1’s PCP confirmed the facility did not contact R1’s PCP following this incident, and no documented physician follow-up occurred until June 3, 2025.