Complaint Investigation Report

According to hospital medical records, resident (R1) was admitted to the hospital on July 30, 2025, after reportedly being pushed by another resident (R2) and falling. R1 was diagnosed with right fourth (4 th ) through eighth (8 th ) rib fractures and right hemothorax. R1 was discharged from the hospital on August 1, 2025. Emergency Medical Services (EMS) records indicated that a staff (unknown) informed them that R1 went into R2’s room and R2 pushed R1 out of their room causing the fall. The Unusual Incident/Injury Report LIC624 indicated that the incident occurred at approximately 7:30am and R1 verbalized that they were pushed by R2. R2’s Behavioral Expressions Monitoring Log indicated that, on July 30, 2025, R2 was agitated, anxious, and frustrated by R1 going into their apartment. R1 was found on the floor and had an unwitnessed fall. R1 indicated that R2 pushed them. R1’s Daily Log, dated July 30, 2025, indicated that R2 pushed them down. According to staff schedules and timecards, there were three (3) care staff present at the care home, with no med tech on duty, at the time of the incident on July 30, 2025. Staff interviews indicated that, due to the facility not having a med tech on duty, staff (S2) was responsible for passing medications. Staff interviews indicated that S2 was pulling medications at the time of the incident between R1 and R2 leaving two (2) care staff available to assist residents. Interviews with staff (S3) and S2 indicated that, upon response to R1’s fall, R1 informed them that they were pushed by R2. Staff interviews indicated that the incident between R1 and R2 was unwitnessed. However, staff interviews also indicated that the facility was aware of R2’s aggressive behaviors and did not ensure there were enough staff scheduled based on the care needs of the residents.

Based on interviews conducted and documentation obtained, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiency is being cited on the attached 9099-D page. As a result of the resident's serious bodily injury, an immediate civil penalty per Health and Safety Code § 1548 in the amount of $500 was assessed on an LIC809 provided on February 19, 2026 for a violation that the Department determines resulted in the injury or illness of a person in care. An additional civil penalty assessment is under review and a determination is pending. LPA will return on a future date to assess an additional civil penalty if warranted.

Exit interview conducted. A copy of the report and appeal rights provided.