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 14, 2025, 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 March 12, 2025. Per incident report, R1 had an unwitnessed fall on July 1, 2025 at approximately 12:30am. Staff last observed R1 at approximately 12:00am. R1 pressed on their pendant and staff found R1 on the floor. Staff called 911. Paramedics arrived at the facility and evaluated R1. Staff requested R1 to be transported to the hospital. Paramedics told staff R1 did not appear to be injured, assisted R1 back to bed, and left. At 7:30am, R1 complained of pain. Staff contacted non-emergency transport services and R1 arrived at the hospital at 8:15am. R1 was diagnosed with a non-operative, unspecified fracture of the left pubis, contusion of unspecified part of head, and fracture of unspecified parts of lumbosacral spine and pelvis. R1 returned to the facility the same day. Interviews with eight out of nine staff stated R1 was evaluated by the paramedics but declined to transport R1 to the hospital as their assessment did not indicate any injuries. The remaining staff stated they are aware of the fall and added there are two caregivers and one med-tech checking on residents at night. The Emergency Medical Incident Report narrative filed by Huntington Beach Fire Department dated July 1, 2025 determined R1 “had no apparent injury or medical complaint. (R1) assisted back to bed.” Although R1 sustained a fall, it remains unclear if the fall occurred as a result of neglect.