Regarding the Allegation: Staff did not get timely medical care for residents. It is being alleged that staff do not provide timely medical care for residents when residents fall. Observations revealed the following: During the investigation the Department noted staff giving morning medications to residents and observed staff moving residents with no issues and there were no negative interactions. Records reviews revealed the following: The incident report (dated 11/07/2025), indicates that on 11/07/2025, R1 had fallen from bed and sustained bruises on both hands and a laceration on the forehead around 6:30 AM. The report states that on 11/07/2025 caregivers did not call 911 or advise facility owner until 7:00 PM. The Department reviewed S1’s termination letter dated 11/14/2025, which indicated that S1 was terminated for not calling 911 and not making S2 aware of incident. Interviews revealed the following: 3 out of 3 staff (S2, S3 and S4) agree that S1 did not provide timely medical care for R1. S2 indicates that R1 fell out of bed and had injuries. S2 indicates that the incident happened at 6:30am and 911 was S2 not called until 6pm. S2 indicates that this was not normal process, that S1 did not call 911 and did not generate an incident report. Resident R1 could not be interviewed as R1 was in the hospital. The Department could not interview residents R2 out of R4 residents due to their medical conditions. Residents R3 and R5 denied the allegation. The Department interviewed W1 who indicates that R1 medical care was not provided timely.

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At this time, an additional civil penalty determination is pending in reference to The Welfare and Institutions Code Section 15610.67 which defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.”

An exit interview was conducted, and plans of corrections were developed and a copy of this report, a copy of the amended Investigation Report (LIC9099D) and appeals rights were provided to Administrator Rodrigo Rosaldo (S1).

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Regarding the Allegation: Staff are not properly trained in how to deal with medical personnel and residents’ medical information. It is being alleged that the facility staff are not trained to work with medical personnel and provide residents with medical information during medical emergencies. On 11/19/2025 the Department observed staff giving morning medications to residents and staff moving residents with no issues and there were no negative interactions. Records indicate the following: The Department reviewed check list (dated 01/06/2025) for staff to follow during emergencies. The following 6 steps were noted on S1-S4 records: 1) check patient, 2) call 911, 3) get a copy of patient ID & insurance card, 4) Get a copy of medication list, 5) call family, 6) generate incident report. Interviews indicate the following: S2 indicates that staff work with medical personnel every week and provide resident medical information when needed. 3 out of 3 staff deny the allegation. R1 cannot be interviewed as R1 was in the hospital. 2 out of 4 residents could not answer any questions due to cognitive issues. R3 and R5 denied the allegation. W1 denied the allegation and indicates seing facility staff work with medical personnel on a weekly basis.

Based on interviews and supporting documentation, the preponderance of evidence standard has been met therefore, the allegation of “staff are not properly trained on how to deal with medical personnel and residents’ medical information” is found to be UNSUBSTANTIATED.

An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Rodrigo Rosaldo (S1).

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