306006071-4-22-2026-22-AS-SSAS-DUMPAG-20260601110844

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006071
Report Date: 04/22/2026
Date Signed: 04/22/2026 12:40:41 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/15/2025 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20250715104426

FACILITY NAME:	PALMS RETIREMENT CENTER		FACILITY NUMBER:	306006071
ADMINISTRATOR:	BARRIENTOS, ELEANOR		FACILITY TYPE:	740
ADDRESS:	312 N ROOSEVELT AVE		TELEPHONE:	(626) 353-4710
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92832
CAPACITY:	144	CENSUS: 106	DATE:	04/22/2026
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Eric Vaca		TIME COMPLETED:	12:41 PM

ALLEGATION(S):

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Resident sustained a fracture after an unwitnessed fall
Staff are not properly supervising resident who may be a fall risk
Staff did not seek timely medical attention for resident in care
Staff are not properly reporting incidents to authorized representatives
Staff are leaving resident in soiled clothing for an extended period of time

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Administrator Eric Vaca and explained the reason for the visit.

During the course of the investigation, Department staff inspected the facility, interviewed the staff, witnesses and reviewed records, and reviewed voicemails messages, and reviewed documents including, resident roster, staff roster, staff schedule, Resident 1’s (R1) physician’s report dated June 2, 2022, R1’s preplacement appraisal dated May 31, 2022, elopement risk assessment dated May 51, 2022, R1’s functional capabilities assessment, R1’s Appraisal/Needs and Services Plan dated May 16, 2025, R1’s Admission Agreement dated May 13, 2025, R1’s consent for emergency medical treatment dated May, 13, 2025, R1’s care notes for May and June 2025, R1’s physician’s report dated May 7, 2025, R1’s resident appraisal dated May 12, 2025, and St. Jude Medical Records for R1 dated July 7, 2025 to July 21, 2025.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 22-AS-20250715104426

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PALMS RETIREMENT CENTER	FACILITY NUMBER: 306006071
	VISIT DATE: 04/22/2026

NARRATIVE

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The investigation into the allegation, Staff are not properly reporting incidents to authorized representatives, revealed the following. It was reported that R1 sustained falls on June 9, 2025 and July 2, 2025 and R1's authorized representative/emergency contact was not notified. A review of records shows R1 sustained falls on June 21, 2025, and July 7, 2025. The Administrator reported there is no record of any falls for R1 on June 9 or July 2, 2025. R1 could not recall how many times or the dates of when they have suffered a fall. The Wellness Director reported that they have no record of falls for R1 on June 9 or July 2, 2025. 5 out of 5 staff members reported they are unaware of any falls for R1 on June 9 or July 2, 2025. R1's authorized representative/emergency contact reported that they were notified about the falls on June 21 and July 7, 2025. R1's authorized representative/emergency contact could provide any details about the falls reported to have taken place on June 9 or July 2, 2025. None of the evidence gathered supports the allegation, therefore the allegation is deemed Unsubstantiated, meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, staff are leaving resident in soiled clothing for an extended period of time, revealed the following. It was reported that R1 was not properly assisted with incontinence issues and would be left in their soiled clothes for an hour before they were assisted and changed and this caused R1 to be hospitalized. No specific details were provided as to when or how many times this occurred. R1's physician reported that R1's hospitalization and diagnosis of Sepsis secondary to UTI could not be attributed to poor hygiene and was caused by their overall poor health. The Administrator and Wellness Director reported they were unaware of any issues assisting R1 with incontinence issues and have heard no reports of residents being left in soiled clothing. 5 out of 5 staff members reported that R1 was not neglected in any way, was never left in soiled clothing and they constantly checked on R1. R1 declined to comment when questioned about specific care provided by facility staff. R1 offered no explanation for this. None of the evidence gathered supports the allegation, therefore the allegation is deemed Unsubstantiated, meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and a copy of the report provided.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 22-AS-20250715104426

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PALMS RETIREMENT CENTER	FACILITY NUMBER: 306006071
	VISIT DATE: 04/22/2026

NARRATIVE

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The investigation into the allegation, staff are not properly supervising residents who may be a fall risk, revealed the following. It was reported that R1 was known to fall risk and the facility failed to properly monitor R1 which led to numerous falls. R1 moved into the facility on May 13, 2025. R1 was diagnosed with polyneuropathy, Type II Diabetes, Chronic Obtrusive Pulmonary Disease (COPD), obesity, heart failure and chronic pain. R1’s psychiatric diagnosis includes bipolar disorder, depression, anxiety and psychotic disorder. R1 can communicate, is alert and oriented to time and place but experiences episodes of confusion. R1 can communicate their needs effectively and could follow instructions. According to the facility staff and R1’s physician R1 is a fall risk. According to R1’s physician R1 could walk 6 to 8 feet independently but required an assistive device or staff support for any distance beyond that. R1 was placed in a room near the medical technician’s office so they could be closer to staff and easier to monitor. R1’s physician reported that R1’s ability to communicate their needs and follow instructions meant one on one care was not clinically necessary. R1 utilized a motorized wheelchair and required assistance when transferring, bathing, dressing and incontinence care. R1 sustained fall on June 21, 2025, and July 7, 2025. The fall in June did not result in any injuries. A review of records shows R1 was on hourly safety checks. The Administrator, Wellness Director and 5 staff members reported that all staff members follow R1’s care plan that calls for hourly checks and for staff to assist with transferring, bathing, dressing and incontinence care. 5 out of 5 staff members reported that R1 was not neglected in any way and staff constantly checked on R1. R1 declined to comment when questioned about specific care provided by facility staff. R1 offered no explanation for this. R1’s physician reported that in their years attending and examining residents at the facility they have never witnessed any staff neglect. A Licensed Clinical Social Worker who had previously worked with R1 reported that staff attended R1 frequently and they did not observe anything that caused concern. Based on the evidence gathered through document review and interviews, the allegation is deemed Unsubstantiated, meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 22-AS-20250715104426

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PALMS RETIREMENT CENTER	FACILITY NUMBER: 306006071
	VISIT DATE: 04/22/2026

NARRATIVE

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The investigation into the allegation, staff did not seek timely medical attention for resident in care, revealed the following. It was reported that after R1 fell on July 7, 2025, staff did not seek timely medical attention for R1. R1 moved into the facility on May 13, 2025. R1 was diagnosed with polyneuropathy, Type II Diabetes, Chronic Obtrusive Pulmonary Disease (COPD), obesity, heart failure and chronic pain. R1’s psychiatric diagnosis includes bipolar disorder, depression, anxiety and psychotic disorder. R1 can communicate, is alert and oriented to time and place but experiences episodes of confusion. R1 can communicate their needs effectively and could follow instructions. According to the facility staff and R1’s physician R1 is a fall risk. According to R1’s physician R1 could walk 6 to 8 feet independently but required an assistive device or staff support for any distance beyond that. R1 was placed in a room near the medical technician’s office so they could be closer to staff and easier to monitor. R1’s physician reported that R1’s ability to communicate their needs and follow instructions meant one on one care was not clinically necessary. R1 utilized a motorized wheelchair and required assistance when transferring, bathing, dressing and incontinence care. On July 7, 2025, R1 was discovered by staff on the floor of their room at approximately 7:00 am to 7:30 am. According to the special incident report dated July 8, 2025, for the fall incident on July 7, 2025, R1 suffered an unwitnessed fall and was in pain and 911 was called. R1 did not recall the time of the fall but reported they were not close to the call button to call for assistance. Staff reported seeing R1 in their bed around 6:00 am. R1 reported that they were transferring from their bed to their wheelchair unassisted when they fell. R1 did not have an explanation as to what caused the fall. R1 did report that they suffered memory loss following the fall on July 7, 2025, but did not provide any additional details. R1 declined to comment when questioned about specific care provided by facility staff. R1 offered no explanation for this. It was reported that the only reason 911 was called was because of R1’s insistence. A voicemail was provided to support this claim. A review of the voicemail shows facility staff (S1) called R1’s responsible party informing them R1 was sent to the hospital because they had a fall and R1 wanted to be sent to the hospital. S1 no longer works for the facility and never responded to a request for an interview. A review of hospital records shows that R1 was admitted to the hospital at 8:10 am on July 7, 2025. A review of facility records shows that R1 requested and received hospital transport several times for various reasons between their move in date, May 13, 2025, and the incident on July 7, 2025. It is unclear who prompted the 911 call. R1 was transported to the hospital shortly after their fall, therefore the allegation is deemed Unsubstantiated, meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 22-AS-20250715104426

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PALMS RETIREMENT CENTER	FACILITY NUMBER: 306006071
	VISIT DATE: 04/22/2026

NARRATIVE

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The investigation into the allegation, resident sustained a fracture after an unwitnessed fall, revealed the following.

It was reported that a lack of care and supervision resulted in R1 sustaining a fall that caused a fracture. R1 moved into the facility on May 13, 2025. R1 was diagnosed with polyneuropathy, Type II Diabetes, Chronic Obtrusive Pulmonary Disease (COPD), obesity, heart failure and chronic pain. R1’s psychiatric diagnosis includes bipolar disorder, depression, anxiety and psychotic disorder. R1 can communicate, is alert and oriented to time and place but experiences episodes of confusion. R1 can communicate their needs effectively and could follow instructions. According to the facility staff and R1’s physician R1 is a fall risk. According to R1’s physician R1 could walk 6 to 8 feet independently but required an assistive device or staff support for any distance beyond that. R1 was placed in a room near the medical technician’s office so they could be closer to staff and easier to monitor. R1’s physician reported that R1’s ability to communicate their needs and follow instructions meant one on one care was not clinically necessary. R1 sustained fall on June 21, 2025, and July 7, 2025. The fall in June did not result in any injuries. A review of records shows R1 was on hourly safety checks. The Administrator, Wellness Director and 5 staff members interviewed reported that R1 was constantly checked and assisted throughout the day. On July 7, 2025, R1 was discovered by staff on the floor of their room from approximately 7:00 am to 7:30 am. R1 did not recall the time of the fall but reported they were not close to the call button to call for assistance. Staff reported seeing R1 in their bed around 6:00 am. R1 reported that they were transferring from their bed to their wheelchair unassisted when they fell. R1 did not have an explanation as to what caused the fall. R1 declined to comment when questioned about specific care provided by facility staff. R1 offered no explanation for this. Staff found R1 on the floor of their room and called 911. R1 was transported to the hospital. R1 was diagnosed with a closed fracture of the fourth lumbar vertebra and Sepsis secondary to UTI. R1 was at the hospital from July 7, 2025, to July 21, 2025. On July 21, 2025, R1 was transferred to a skilled nursing facility (SNF). Based on the evidence gathered from a review of records, interviews from 7 staff members, R1’s physician and clinical social worker, the allegation is deemed Unsubstantiated, meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 5