Abstract: At approximately 10:00 a.m. on December 21, 2013, Employee #1, a painter employed by a construction contractor, was engaged in interior remodeling/alterations work at a restaurant. His employer was the general contractor for the project. However, there was no foreman at the site, and all workers other than Employee #1 were employed by subcontractors. Employee #1 was patching drywall near and on the 14-foot ceiling while standing on a Werner 10-foot fiberglass step ladder. This extra heavy duty ladder had a rated working load of 300 pounds. Employee #1 was 5 feet 4 inches tall and weighed 163 pounds. Employee #1 was holding the patching compound and spatula while standing on the second step below the topcap of the step ladder. The ladder tipped to one side, and Employee #1 fell to the ground, a fall height of 10 feet. Nearby subcontractor workers heard the fall and saw Employee #1 lying on the ground in pain. They phoned a foreman who was at another location. The foreman came to the restaurant and called for emergency services. An ambulance arrived, and Employee #1 was transported to San Francisco General Hospital. He was admitted and treated for compressed neck vertebrae, a large hematoma on the right upper side of his head, nerve damage, and spinal pain. He remained hospitalized for four days. This event was reported to Cal/OSHA on either December 21 or December 23, 2013, by a relative of Employee #1. During the subsequent investigation, begun at the job site on January 10, 2014, interviews were conducted with the employer, Employee #1, and Employee #1's relative. It was established that Employee #1 was standing on the second step below the ladder's topcap, and this step was 7 feet 8 inches above the ground. He was leaning past the ladder side rails while patching the drywall. His work position contributed to his fall. The investigation revealed conflicting versions of what happened next and how soon the ambulance arrived. Initially, the size and height of the step ladder also were in dispute. According to Employee #1, after he fell he had to wait approximately 45 minutes for a foreman to arrive from another jobsite. When the foreman arrived, he removed the fallen ladder and wanted to move Employee #1 to his (Employee #1's) house before contacting an ambulance. Employee #1, who was still on the ground, was screaming in pain and said not to move or touch him and to call the ambulance. The foreman finally made the call for emergency services. In contrast, according to the employer, a foreman employed by another company, who was doing the employer a favor by opening up the jobsite while the employer was away in Canada, called him and reported the fall event to him. The employer then instructed the foreman to go to the jobsite. According to the employer, who stated he was on the phone with the foreman the entire time, it took the foreman approximately 10 minutes to arrive at the job site. When the foreman arrived, the employer told him to call emergency services. Based on the Cal/OSHA investigation, the employer was cited a general accident-related violation: T8 CCR '3276(e)(15)(A) requires employees to work near the middle of the step and not to overreach. Other standards relating to ladders were violated, and the employer was cited accordingly. However, the investigation was not able to establish employer knowledge. At the time of the investigation report, Employee #1 was taking six different prescribed medications daily, wearing a frontal neck brace to minimize vertical movement, and walking with a cane. He had experienced three seizures, each requiring emergency services and transport to the hospital. In addition, Workers' Compensation documents had not been given to Employee #1, and he had not received wages for the work performed on December 21, 2013, the day of the fall.