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 February 9, 2026, the Orange County Regional Office received an incident report regarding an unwitnessed fall of Resident 1 (R1). The investigation determined the following:

R1 was admitted to the facility on November 1, 2025. Per incident report, R1 had an unwitnessed fall on February 3, 2026. Staff was present when R1 fell, but they did not witness the fall itself. R1 was transported to the hospital on February 3, 2026, where an X-ray of the right shoulder revealed an acute neck fracture. R1 was treated and returned to the facility the same day. Interviews with six out of six staff stated R1 was able to ambulate with a walker or cane prior to the fall. Three out of those six staff added fall mitigation measures were implemented including lowering R1’s bed to the lowest position; placing a mat next to the bed; having R1 participate in physical therapy; and enrolling R1 in a toileting program that takes R1 to the bathroom every two to three hours. R1’s physician report dated October 28, 2025, did not indicate any motor impairment and noted R1 was able to transfer independently to and from bed. The physician’s report indicated R1 was ambulatory. Per R1’s Resident Assessment dated November 1, 2025, R1 ambulates without assistive devices and was independent in mobility but used a cane. Although R1 sustained a fall, it remains unclear if the fall occurred as a result of neglect.