Complaint Investigation Report

415601039-3-1-2024-14-AS-KHOS-D46MMP-20240409094415

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SAN BRUNO RO , 851 TRAEGER AVE., SUITE 360

This is an official report of an unannounced visit/investigation of a complaint received in our office on

08/04/2023 and conducted by Evaluator Jaime Vado

COMPLAINT CONTROL NUMBER: 14-AS-20230804102303

Health and wellness diretor - Marquita Kennedy and Business office director Margaret Madrid

- Resident sustained multiple falls and injuries while in care

AMENDED REPORT OF LIC9099A DATED 02/22/2024

On 03/01/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver amended LIC9099 report and deliver findings regarding the allegations listed above. LPA met with --- and explained the purpose of today's visit.

During the complaint investigation it was discovered that the resident had several documented falls - March 2022, February 2023, April 2023, and May 2023. On May 29, 2023 the resident had an unwitnessed fall, and based on interviews no one knew where the staff were and no staff were present to supervise the resident. The resident suffered significant injury which resulted in hospitalization and an arm separation was as a result of the fall. April 2023 fall the resident was evaluated at the hospital and released on the same day. After multiple falls in the facility there were no reappraisals done for the resident although the facility identified the resident as a fall risk. The facility failed to reassess the resident, establish, and update safety measures to prevent falls after sustaining these multiple falls to meet the resident's needs.

Based on LPA interviews and items letters received, 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, are being cited on the attached LIC9099D.