The complaint alleged that the client (C1) was admitted to hospital on 01/07/2024 for a fall. On June 5, 2026, the department interviewed the Administrator (A1), who denied the allegations. A1 stated that C1 got out of bed to use the bathroom without calling for staff assistance and did not use a walker. Suddenly, the staff heard a noise and discovered C1 on the bathroom floor. A1 reported that the staff immediately called Emergency Services (ES), who transported C1 to Riverside University Health System (RUHS), where C1 was admitted with a fractured left tibia on 01/07/2024 and discharged on 01/10/2024.

On the same day, the department interviewed two staff members, C1 and C2, both of whom confirmed they had received fall-prevention training. The department also interviewed two clients, identified as C1 and C2, who reported that staff members assisted them when needed. Client C1 reported that they previously disliked using a walker or asking for assistance. However, they now call for help when necessary and have begun using a wheelchair instead of a walker.

Additionally, the department attempted to interview four other clients (C3 to C6), but unfortunately, they were unable to answer any questions due to their health conditions.

Report continued on LIC9099C

On June 10, 2026, the department contacted the Placement Agency, which stated that, after its investigation was complete, the case was closed on 08/29/2024. No citations were issued.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Allegation #2: Staff do not ensure resident's hygiene needs are being met.

The complaint alleged that the client appeared “pretty disheveled, and C1’s hair was messy.” On June 5, 2026, the department interviewed the Administrator (A1), who denied the allegation, explaining that the incident occurred around 11:30 PM, in the middle of the night. It was expected that the client would not be well-dressed and that their hair would be unkempt, as they had fallen asleep before the incident. On the same day, the department interviewed two staff members (S1 and S2), both of whom also denied the allegation. They stated that the client's hygiene needs are met daily and that clients who wear diapers are changed every two hours or as needed. Additionally, the department spoke with two clients (C1 and C2), both of whom denied the allegations, stating that staff assist them with their hygiene and daily living needs.

On June 10, 2026, the department contacted the Placement Agency, which stated that, after its investigation was complete, the case was closed on 08/29/2024. No citations were issued.

The department reviewed records, including a physician's report for Client C1 dated April 26, 2024. The department also reviewed the facility's records on staff training in Assisted Daily Living (ADL) for clients and in clients' personal rights.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies were cited.

An exit interview was conducted. A copy of this report was provided to the Administrator, Cotadela Balatbat.