Complaint Investigation Report

R1 was found sitting on the floor in-between their walker and bed. R1 reported to S1 that they stood up and felt dizzy. R1 reportedly attempted to sit back down onto the bed and fell to the floor. Staff #2 (S2) assessed R1 where no injuries were observed but R1 complained of pain their low back region. Emergency services were reportedly contacted and transported R1 for further evaluation. A records request submitted to the California Department of Forestry and Fire Protection did not report receiving an emergency alert on 7/8/2026 but makes note of an incident involving R1 on 7/10/2026. A records request was submitted to American Medical Response on 6/5/2026. LPA conducted multiple follow-ups with no success. Discharge paperwork received for R1 from a visit at the hospital on 7/8/2025 reports that R1 was experiencing symptoms unrelated to a cerebrovascular accident. Discharge paperwork notes that R1 was admitted into the hospital at 9:00AM on 7/8/2025 and was later released back into the community on the same day with after-care instructions. An interview conducted with S1 reports that they do not recall specifics about the incident but denied the allegation of staff not seeking timely medical care for R1. LPA Flores conducted several interview attempts with S2, but attempts were unsuccessful. LPA conducted several interview attempts with R1, but interview attempts were unsuccessful as R1 refused or chose not to engage in conversation with LPA Flores.

Witness #1 (W1) alleged staff did not provide care and supervision to Resident #1 (R1) leaving R1 in their room unattended all day. Interviews conducted with (6) six staff report that residents receive health check approximately every two hours. If a resident returned from the hospital or is experiencing a change of condition, residents will be placed on alert health checks which are conducted every 30 minutes. An interview was conducted with the Administrator whom vague recalls key information into the incident. The Administrator reports that during a shift change, the following shift reported concerns of R1 possibly not being checked on as needed but Administrator believes it to be a miscommunication. Administrator stated that staff are expected to conduct health checks on a regular basis that do not exceed a residents care plan or a two-hour time period. An interview conducted with S1 reports that they did not recall specific details of the incident but denied the allegation of staff not providing adequate care and supervision to R1. LPA Flores conducted several interview attempts with S2, but attempts were unsuccessful. LPA conducted several interview attempts with R1, but interview attempts were unsuccessful as R1 refused or chose not to engage in conversation with LPA Flores.