Complaint Investigation Report

R1 was sent to the hospital several times due to the falls, and during the falls had sustained a left hip fracture 6/11/2024 and a right hip fracture 08/2024 while residing in assisted living. S2 said they completed multiple assessments and recommended additional supervision for R1. Staff reported that additional status checks were implemented and R1s medications were changed by physician to assist R1 with sleep and anxiety. Facility staff notified family during any change of condition or when an incident occurred. The incident was documented, and timely medical care was provided.

R1 had nine falls while residing in assisted living and three falls within one month of residing in memory care. On 09/05/24, the facility had a care conference with the family recommending a personal caregiver and a higher level of care for R1. R1 had six additional falls after the care conference.

At the time of the complaint visit, Resident Care Coordinator Patricia Pestano was informed that the incident is currently under review and a future civil penalty may apply based on Health and Safety Code § 1569.49.

Based on interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099D. An Immediate Civil Penalty of $500.00 was also assessed/charged (refer to the LIC421-IM page). An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Resident Care Coordinator Patricia Pestano, whose signature below confirms receipt of these rights.