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 July 17, 2025, the Orange County Regional Office received an incident report regarding an unwitnessed fall of Resident 1 (R1). The investigation determined the following:

R1 had been admitted to the facility on December 31, 2021, and was a documented fall risk per facility fall risk assessment conducted on December 15, 2021. R1 sustained unwitnessed falls on April 14, 2023; January 4, 2025; January 5, 2025; March 11, 2025; June 19, 2025; July 5, 2025; and July 11, 2025. Physician communications between the facility and R1’s physician and facility progress notes for R1 confirmed R1 sustained a total of seven falls. Although R1’s assessment appraisals was updated at least six times during the falls and identified them as a fall risk, the facility did not document or implement specific fall-prevention interventions or mitigation measures.

On July 11, 2025, at approximately 4:30am, R1 was found on the floor of their apartment following an unwitnessed fall as indicated on the progress note and physician communication for R1 dated the same day. Interviews with two out of three facility staff confirmed that R1 did not activate their pendant to request assistance. All three staff interviewed reported that no routine safety checks were conducted during the night shift for R1 despite R1’s history of falls. Facility records documented that R1 had signed a Night Shift Resident Check Waiver during the admission process on December 15,2021 indicating they did not want to be checked on during the night, despite R1 being identified as a fall risk.