Facility Evaluation Report

LPA Serrano arrived at the facility to deliver a case management investigation report related to a fall experienced by Resident 1 (R1) on 10/20/2025 and concerns regarding the facility’s response, medical assessment practices, supervision, and change in condition procedures. LPA met with Executive Director Abraham Botello and discussed the purpose of the visit.

R1 moved into the independent living area on 10/28/2020 and did not require assistance with daily activities at the time of admission. On 10/20/2025, R1 contacted the front desk and requested help after they fell inside their room. Staff 1 (S1) responded and helped R1 up from the floor. S1 stated that R1 reported hitting their head during the fall. S1 reported that R1 appeared to have no visible injuries and reportedly refused medical care. Staff 2 and Staff 3 also responded to the call but did not enter the room or assess R1 for injuries.

The Department interviewed the Administrator, who stated they believed R1 had no fall history prior to the 10/20/2025 incident. The Department reviewed R1’s facility records and identified a total of nine falls dating back to January 2024 . All but one occurred in R1’s room and were unwitnessed. Three of these falls resulted in hospital transport for serious injuries, including hip injuries. Records also indicated R1 hit their head in at least two prior falls. Additional documentation showed multiple hospital transports for breathing issues and other medical conditions. The only Physician’s Report available was dated 10/1/2020 , with no updated assessments on file.

The Department conducted a follow-up interview with the Administrator. The Administrator stated they had only been in their role for a few months and were unaware of R1’s fall history.