Complaint Investigation Report

Additionally, interviews conducted did not reveal any corroborated statements or evidence of lack of appropriate care and supervision of R1. Interviews confirmed date and time of fall with description of R1 found on the floor outside the door of this room with walker beside him. Staff on duty provided pillows for comfort without moving R1 for safety purposes while awaiting for 911 personnel to arrive and assess. Interviews revealed 911 was notified within 1-2 minutes of discovery of fall. Incident was reported to licensing department on or about 8-1-2025.

As a result of the above investigation, it was determined that R1 sustained a fall with possible sacral fracture. It was further determined that although this incident occurred, there is not a preponderance of evidence to conclude this incident was due to a lack of adequate care and supervision or other violation of Title 22 or Health and Safety Code violations, therefore, this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights provided.