Complaint Investigation Report

LPAs interviewed Residents R1-R10. 9 Out of 10 residents (R2-R10) stated caregivers are providing assistance in a timely manner when resident’s request for assistance. R1 stated approximately 3 to 4 weeks ago he/she sustained a fall in the morning in his/her bathroom. R1 stated he/she was yelling for help for approximately 20 to 30 minutes until a caregiver arrived.

During the visit LPAs tested pendant in Room #222. The facility responded to this pendant test in 17 minutes and 30 seconds. (LPAs observed resident in #223 exit his/her room and requested for water. LPAs observed caregiver leave the area to get the resident the requested water, the caregiver then responded to resident in Room #222). LPAs also tested pendant in Room #226. A caregiver responded in 2 minutes to the pendant call in Room #226.

LPAs interviewed Care Coordinator (CC). CC stated the facility has an extra staff in the morning shift and the facility is not short staffed. CC stated he/she has no knowledge of R1 falling or R1 being hospitalization in the past two months.

LPAs reviewed progress notes for R1 for the months of April 2025 and May 2025. There were no documented falls for R1. LPAs also reviewed R1s hospital visits/fax communication file, and there is no mention or documentation of R1 falling in April 2025 and May 2025.

LPAs reviewed facility incident reports. There were not documented falls or hospitalization's for R1 in April 2025 and May 2025.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED . An unsubstantiated findin g indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did

No deficiencies cited during today's visit per California Code of Regulations Title 22. An exit interview was conducted with Care Coordinator (CC) Gregg Madriaga and signed copy of this report was provided.