NARRATIVE |
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32 | Physician’s Report for R1 (04/24/24), Physician Orders for Life‑Sustaining Treatment (POLST) for R1, Individual Service Plan from Assisted Living Waiver (ALW) Program (4/23/2024) , Durable Power of Attorney for R1, and Assessment Tool generated by Carling Connection for the Assisted Living Waiver Program for R1 (4/23/2024). LPA Troy Watson interviewed Staff #1-#5 (S1-S5) and administrator Narine Mertkhanyan (A1) and Residents #2-13 (R2-R13). An attempt to interview Resident#1 was made but (R1) was not available at the facility during the time of visit.
Investigation revealed the following:
Allegation: Staff did not seek timely medical care for a resident
It is being alleged that facility staff failed to provide timely medical care after R1 experienced a fall, which resulted in a hospitalization for a leg fracture. On 11/17/2024, LPA Troy Watson interviewed Administrator Narine Mertkhanyan (A1). During the interview conducted on 11/17/2024, Administrator Narine Mertkhanyan (A1) stated that R1 had no known history of falls and that the incident in question was the only documented fall during R1’s stay at the facility. A1 also reported that R1 was in hospice prior to being admitted and continued hospice with a nurse periodically checking on her throughout the night. On 12/23/2025, LPA Troy Watson interviewed Staff #1–5 (S1–S5). Out of those interviewed 5 out of 5 staff members denied the allegation. On 12/23/2025, LPA Troy Watson interviewed Residents #2–13 (R2–R13). Out of those interviewed 12 out of 12 residents denied the allegation.LPA Troy Watson obtained and reviewed facility and medical records for R1. Per R1’s Face Sheet, R1 was admitted to the facility on 10/29/2024. A Facility Internal Occurrence Report dated 10/31/2024 states that a caregiver reported R1 had an unwitnessed fall, after which the Wellness Coordinator assessed R1 and noted scratches to the hand but no other injuries. Facility Notes and Alert Charting dated 11/01/2024 indicate that the caregiver reported that on 10/31/2024, R1 was found on the floor. The 11/01/2024 charting also notes that a body check was completed, revealing no injuries other than to the left hand, although R1 complained of leg pain. Facility Notes and Alert Charting dated 11/02/2024 documents that the hospice agency requested an X-ray. LPA Troy Watson reviewed Vitas Hospice notes dated 11/01/2024 through 11/03/2024 which confirm that R1 remained at the facility during that period. On 11/04/2024, Facility Notes and Alert Charting indicate that R1’s family had R1 sent to UCLA Hospital.
CONTINUED ON LIC9099-C |
NARRATIVE |
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32 | Records from Ronald Reagan UCLA Medical Center show that R1 was admitted on 11/04/2024, and X-rays taken upon admission showing an acute distal fibular diaphysis transverse fracture with half shaft width lateral displacement of the distal fracture fragment.. No documents were provided by facility indicating any other medical interventions were provided by facility to R1 from the date of fall on 10/31/2024 to date of hospitalization on 11/4/2024.
Based on interviews and record reviews, the preponderance of evidence has been met; therefore, the allegation is Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099D.
Allegation: Due to lack of supervision, a resident fell resulting in a fracture.
It is being alleged that facility staff did not complete a proper assessment of resident 1 (R1) and had no knowledge of R1 being a fall risk, which led to R1 falling and sustaining a fracture. On 11/17/2024, LPA Troy Watson interviewed Administrator Narine Mertkhanyan (administrator 1-A1) regarding the circumstances surrounding R1’s fall. A1 stated that R1 had no known history of falls and that the incident in question was the only documented fall during R1’s stay at the facility. LPA Troy Watson reviewed facility records. Facility provided department with a copy of the Assisted Living Waiver Individual Service Plan dated 04/23/2024, when R1 still lived in their own home, and it identified R1 as a fall risk. LPA Watson requested from the facility a Needs and Service Plan, Fall Risk Plan and Preplacement Appraisal but none were provided. On 12/23/2025 LPA Troy Watson interviewed Staff #1–5 (S1–S5). Out of those interviewed 5 out of 5 staff members denied the above allegation. On 12/23/2025 LPA Troy Watson interviewed Residents #2-#13 (R2-R13). Out of those interviewed 12 out of 12 residents denied the above allegation. LPA Troy Watson obtained and reviewed records for R1. Facility Internal Occurrence report dated 10/31 states caregiver reported that R1 had an unwitnessed fall. R1 was checked by Wellness Coordinator who noted scratches to R1’s hand but no other injuries. Per medical records from Ronald Reagan UCLA Medical Center, R1 was admitted to Ronald Reagan UCLA Medical Center on 11/04/2024 with a diagnosis of an acute distal fibular diaphysis transverse fracture with half-shaft-width lateral displacement of the distal fracture fragment. R1 was discharged to a skilled nursing facility on 11/08/2024.
CONTINUED ON LIC9099-D
|
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
01/16/2026
Section Cited
CCR
87465(a)(1)(g) | 1
2
3
4
5
6
7 | Incidental Medical and Dental Care
A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
This requirement is not met as evidenced by: | 1
2
3
4
5
6
7 | The licensee shall ensure that all staff are retrained on the facility’s policies and procedures regarding responding to changes in a resident’s condition and seeking timely medical care. Licensee will submit training plan to submitted to the Department via email or fax by POC due date. |
 | 8
9
10
11
12
13
14 | Based on interviews and records review, R1 experienced an unwitnessed fall on 10/31/2024, and despite telling staff their leg was injured, R1 was not seen by a physician until they were admitted to Ronald Reagan UCLA Medical Center on 11/04/2024 and diagnosed with a distal tibial and fibular diaphysis fracture. This violation posed an immediate health, and safety risk to residents in care. | 8
9
10
11
12
13
14 | |
Under Appeal
Type A
01/16/2026
Section Cited
CCR
87468.2(a)(4) | 1
2
3
4
5
6
7 | Additional Personal Rights of Residents in Privately Operated Facilities
In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement was not met as evidenced by:
| 1
2
3
4
5
6
7 | The licensee shall retrain all staff on intake assessments, appraisals and monitoring residents who are at risk of falls. Licensee will submit training plan to submitted to the Department via email or fax by POC due date.. |
| 8
9
10
11
12
13
14 | Based on interviews and record review, the licensee did not ensure adequate supervision for Resident 1. Staff failed to provide the level of care and supervision necessary to meet the residents’ needs, which resulted in R1 experiencing a fall that caused a fracture. This lack of supervision posed an immediate health and safety risk to the residents in care. | 8
9
10
11
12
13
14 | |