Complaint Investigation Report

In addition, staff interviewed had conflicting information on whether R1 was a fall risk or not. Facility staff were unaware of R1's injuries and did not document or notice any changes in condition nor how the injury could have been sustained. Based on medical records, on 10/13/24, R1 was transported to the hospital and three x-ray views of R1's left hip did not show any fracture at the time. Further evaluation with cross-sectional imagining was recommended and conducted on 10/16/24 where a computed tomography (CT) scan was conduct of his/her left hip for a possible fall. Medical documentation indicated that the CT scan showed that R1 had an acute non-displaced fracture through the base of the left superior pubic ramus and through the mid left inferior pubic ramus.

Based on the investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Failure to correct said deficiencies may result in additional civil penalties.

AN IMMEDIATE CIVIL PENALTY OF $500.00 WAS ASSESSED TODAY: $500 FOR THE VIOLATION AS R1 SUSTAINED UNEXPLAINED FRACTURE WHILE IN CARE.

A repeat civil penalty of $500 was issued today due to the same violation being cited on 5/27/25.

Due to immediate civil penatly of $500 being cited and repeat civil penalty of $500 being cited, total civil penalty being issued today is $1,000

THE INTERIM EXECUTIVE DIRECTOR WAS INFORMED THAT AN ADDITIONAL CIVIL PENALTY IS STILL BEING DETERMINED AND MIGHT BE ASSESSED BASED ON HEALTH AND SAFETY CODE §1569.49.

Report is reviewed with the Interim Executive Director and a copy is provided with appeal rights.