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32 | Regarding the allegation Licensee did not arrange or assist medical care for resident. On 06/19/2021 at 7:30 a.m., staff contacted R1’s responsible party and informed them that R1 had fallen, but did not disclose that R1 had been on the floor all night or that pendant response was delayed. Facility staff did not arrange immediate medical evaluation following the fall. Instead, the responsible party transported R1 to the hospital several hours later, where R1 was admitted with a spinal cord injury. Based on interviews conducted and hospital admission records, the facility did not ensure timely medical care was arranged for R1 after a known fall incident. The preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED.
Regarding the allegation Facility did not provide adequate lighting. During the 06/18/2021 blackout, R1’s apartment did not have access to backup lighting. The only available fluorescent light in the bathroom did not illuminate the remainder of the unit. R1 attempted to locate their walker and pendant in complete darkness, resulting in a fall. Staff and supervisory personnel confirmed the facility did not have a generator or battery-operated lighting accessible to residents during the blackout. Facility policy requires ensuring resident safety during emergencies; however, residents were not provided adequate lighting. The preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED.
Regarding the allegation Licensee did not follow reporting requirements. Records review and interviews confirmed that the facility did not notify the licensing agency of R1’s fall, extended time on the floor, or hospitalization. Supervisory staff were also not immediately informed of the blackout and fall until contacted by the responsible party. Based on interviews and documentation reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED.
The following deficiencies are being cited (see LIC 9099D) from the California Code of Regulations, Title 22, and the California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on H&S Code section 1569.49(f). Failure to correct the deficiencies may result in additional civil penalties.
Exit interview conducted with facility Executive Director, Wes Lavander, and appeal rights provided. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
02/23/2026
Section Cited
CCR
87411(a) | 1
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7 | 87411 — Personnel Requirements (sufficient, competent staff to meet resident needs at all times) The following requirement has not been met as evidenced by:
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7 | All direct care staff will receive training on required welfare checks, emergency response procedures, and timely assistance to residents following an incident. Documentation of training will be maintained in personnel files and submit proof to LPA by POC date of 02/23/2026.
The Administrator will implement a monitoring system to document completion of welfare checks each shift. The Administrator or designee will conduct weekly audits for 30 days to ensure compliance and ongoing monitoring thereafter.
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14 | On 06/18/2021 during a facility-wide power outage, R1 fell in their apartment and remained on the floor overnight without staff assistance until ~0715 on 06/19/2021. Required welfare checks and timely assistance were not provided, resulting in unmet care needs and contributing to a serious injury later diagnosed at the hospital. which poses an immediate, health, safety, or personal rights risk to residents in care.
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Type A
02/23/2026
Section Cited
CCR
87464(a)(1) | 1
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7 | 87465(a)(1) — Incidental Medical and Dental Care (a) 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(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
The following requirement has not been met as evidenced by: | 1
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7 | All direct care staff will be retrained on fall protocols, including immediate assessment, documentation, and timely arrangement of medical services when indicated. Training will include when to contact emergency services versus responsible parties.. Documentation of training and monitoring will be maintained at the facility, and submit poof to LPA by POC date of 02/23/2026. |
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14 | Following the known fall on the morning of 06/19/2021, facility staff did not arrange timely medical evaluation for R1. The responsible party transported R1 to the hospital several hours later, where a spinal cord injury was diagnosed. Facility did not ensure prompt medical care was obtained. which poses an immediate, health, safety, or personal rights risk to residents in care.
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
02/23/2026
Section Cited
CCR
87303(d) | 1
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7 | 87212 Emergency Disaster Plan
(a) Each facility shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available.
The following requirement has not been met as evidenced by: | 1
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7 | The Administrator will conduct a facility-wide inspection to ensure all emergency lighting fixtures are operational and sufficient to ensure resident safety. Any deficiencies will be corrected immediately.Staff will be instructed to promptly report non-functioning or inadequate lighting to management. The Administrator or designee will monitor emergency lighting conditions during monthly safety checks to ensure ongoing compliance, and send Emergency disaster plan to LPA by POC date of 02/23/2026.
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14 | The facility did not have emergency adequate lighting in resident 1's room possibly contributing to a fall sustaining injuries, which poses an immediate health, safety, or personal rights risk to residents in care. | 8
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Type B
03/08/2026
Section Cited
CCR
87211 | 1
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7 | 87211 — Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: The following requirement has not been met as evidenced by: | 1
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7 | All staff will receive retraining on identifying reportable incidents, required timelines, and proper notification procedures, including notifying the licensing agency, supervisory staff, and responsible parties without delay. Documentation of training will be maintained in personnel files and send proof to LPA by POC date of 03/08/2026.
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14 | The facility did not timely report R1’s fall, overnight time on the floor, or subsequent hospitalization to the licensing agency. Supervisory staff were also not promptly notified of the outage and incident until contact by the responsible party the following day, which poses a potential, health, safety, or personal rights risk to residents in care.
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