The details of the complaint alleged that a client was taken to Saint Mary's Medical Center on 11/17/2024 from the facility because the client was altered and had a confused level of consciousness. It was observed and reported in an incident report by the Long Beach Police Department, when the client arrived, the hair on the client’s head was infested with what appeared to be bed bugs and appeared confused and could barely talk. On 6/4/2025, from 10:00am-2:00pm, the department interviewed staff (S1-S5) and clients (C1-C7) regarding the allegation. 4 of 5 staff denied the allegation that Staff did not prevent a client from being infested with insects. Staff stated that the client did not like to take showers or do daily activities of daily living like grooming or showering. They state that the client like to go out of the facility and stay away for long periods of time throughout the day. They also state that they encouraged the client all of the time to take better care of themselves, but they did not. Additionally, they state that they alerted the conservator, but they did nothing to help.

The department interviewed clients (C1-C7) about the allegation and 6 of 7 client’s that were interviewed denied the allegation that Staff did not prevent a client from being infested with insects. The majority of the client’s interviewed stated that they are independent clients and can take care of their own activities of daily living without assistance from staff. They also state that they have not encountered any bed bugs on their person or in their room.

The Department toured the facility and observed rooms 12,15, 16, 17, 18, 20, 22, 26, 28, 30, 40, and room 41 and did not observe any pests, rodents, or bed bugs. The department also observed the kitchen area and the activity area and did not observe any pests. The department reviewed the Pest Control Invoices (Dated: 10/04/24, 10/18/24, 11/1/24, 11/15/24, 12/5/24, 1/6/25, 1/23/25, 2/7/25, 2/20/25, 3/4/25, 3/21/25, 4/3/25) and observed that the facility has bi-monthly service prevention from Impressive Exterminating pest control.

However, the department also reviewed the Long Beach Police Department incident report (Dated:11/17/2024) and St. Mary Medical Center Medical Report (Dated: 11/17/2024) both reports indicated that the client’s hair was infested with insects and or bed bugs and had to be quarantined from other patients. The medical report also revealed that the client was suffering from acute respiratory failure with hypoxia and severe hypothermia when the client was admitted to the hospital.

Report Continued on LIC9099-C

Note: *Citations that are not cleared by the due date of 06/20/25 will have a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared.

Deficiencies are issued and plans of corrections were discussed.

The details of the complaint alleged that a client was taken to Saint Mary's Medical Center on 11/17/2024 from the facility because the client was altered and had a confused level of consciousness. It was observed and reported to the Long Beach Police Department by staff, when the client arrived, that the client’s body was dirty and very skinny. Additionally, the hair on the client’s head was infested with what appeared to be bed bugs and had to be quarantined. On 6/4/2025, from 10:00am-2:00pm, the department interviewed staff (S1-S5) and clients (C1-C7) regarding the allegation. 4 of 5 staff denied the allegation that Staff did not meet the hygiene needs of a client. Staff stated that they observed the client’s appearance and always encouraged the client to take showers, but the client never really wanted to shower and do activities of daily living (ADL). They state that the client was independent and would be gone from the facility for a lot of the time, but they stated that they would inform the conservator and responsible parties when the client refused to participate in ADLs.

The department interviewed clients (C1-C7) about the allegation and 6 of 7 client’s that were interviewed denied the allegation that Staff did not meet the hygiene needs of a client. The majority of the client’s interviewed stated that the staff are meeting their needs and are satisfied with the care and supervision they are receiving at the facility. Clients stated that they are independent and don’t need assistance with grooming, bathing, or dressing.

The department reviewed the Physicians Report (Dated: 02/28/2023, 9/21/2024), Pre-Placement Appraisal Information (Dated:03/1/2023), and Appraisal/Needs and Service Plan (Dated: 03/01/2023) and observed that the client had a steady decline from the time they entered the facility until their hospitalization. The department also reviewed the Long Beach Police Department incident report (Dated:11/17/2024) that stated that upon arrival at Saint Mary’s Medical Center the client’s body was dirty.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff did not meet the hygiene needs of a client. 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 because of neglect, therefore the allegation is Unsubstantiated.

Report Continued On LIC9099-C

The details of the complaint alleged that a client was taken to Saint Mary's Medical Center on 11/17/2024 from the facility because the client was altered and had a confused level of consciousness. It was observed and reported in an incident report by the Long Beach Police Department, when the client arrived, that the client’s body was very skinny and the client’s skin throughout their body appeared shrunken in. On 6/4/2025, from 10:00am-2:00pm, the department interviewed staff (S1-S5) and clients (C1-C7) regarding the allegation. 4 of 5 staff stated that the client was losing weight and looked thin. They stated that they encouraged the client to eat more but that the client was very picky about what they ate. All staff stated that the facility serves three meals per day and snacks are provided twice per day. They also state that the client would be gone from the facility a lot of the time.

The department interviewed clients (C1-C7) about the allegation and 6 of 7 client’s that were interviewed denied the allegation that Staff did not ensure a client was properly fed while in care. The majority of the client’s interviewed stated that the staff serves three meals per day and that they get snacks as well. They also state that they were satisfied with the food, care, and supervision the staff are providing to them.

The Department toured the facility and observed that the facility has enough perishable and non-perishable food to feed the clients in care. The department reviewed St. Mary Medical Center Medical Report (Dated: 11/17/2024) and observed that the client was diagnosed with Cachexia (Wasting Syndrome) a severe, multifactorial condition characterized by significant loss of skeletal muscle mass and adipose tissue, frequently observed in patients with chronic illness, and other long-term illnesses according to ncbi.nlm.nih.gov.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff did not ensure a client was properly fed while in care. 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 because of neglect, therefore the allegation is Unsubstantiated.

No citations were issued.

An exit interview was conducted with Jemimah Mejia, Administrator, and a hard copy of this Complaint Investigation Report was provided.