Licensing Program Analyst (LPA) Mario Leon conducted a subsequent visit to the facility on 11/17/23 and met with Staff #6 (S6: Angelie Pasa, Health Services Director) who assisted with the visit; as the Administrator was unavailable. LPA conducted interviews with five (5) residents (R1-R5) and four (4) staff members (S1-S4). Interview was not conducted of R6 due to resident’s hospitalization.

Investigation revealed the following:

Regarding Allegation #1: It is alleged that in September 2020, Resident #6 (R6) was hospitalized because the facility gave R6 medication that was not prescribed to the resident. Resident #6 was found in their bedroom "unresponsive." Torrance Memorial Hospital medical records (dated 09/27/20) indicated that R6’s family member is at bedside and stated that the patient (R6) is acting the same as normal. R6’s family member stated that patient’s (R6) speech is the same as when they arrived to the hospital. Medical records documented that there is no “acute neurologic event” nor “acute coronary syndrome, sepsis or other medical or surgical emergency at this time.” In addition, “slurred speech appears to be at baseline for patient (R6). Patient (R6) discharged back to assisted living.” Interviews conducted of Residents (R1- R5) corroborated that they do not feel that they have been overmedicated and would be aware. Interview was not conducted of R6 due to resident’s hospitalization. Interviews conducted of facility staff (S1–S5) corroborated that they have never overmedicated a resident. With each medication received from their physician’s order, it’s sent to the pharmacy (Pharmerica). The pharmacy overlooks and inputs into the resident’s QMAR (electronic MARs). Once facility receives resident’s medication(s), facility staff follows medication(s) instructions, signs the QMAR - after administering the medication. If it’s not signed, a reason is given as to why the QMAR was not signed off. [A review of the facility’s incident reports (September 2020) did not show facility reporting a medication error. A review of the resident’s MAR (Sept 2020) documented signatures following medication administration to R6. Facility staff confirmed that they have received the required in-service training on the topic of administering medications.]

Based on the evidence gathered, interviews conducted, and records reviewed, 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 of MEDICATION: Resident was overmedicated resulting in hospitalization is found to be UNSUBSTANTIATED.

Based on the evidence gathered, interviews conducted, and records reviewed, 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 of NEGLECT/LACK OF SUPERVISION: Resident developed dehydration while in care is found to be UNSUBSTANTIATED.

Regarding Allegation #3: It is alleged that a female caregiver would hide out a lot in R6’s room on their breaks. When they wanted to sleep, this caregiver would tell R6 "this is not your room" and take R6 out of their bed and make them lay on the floor while female caregiver would sleep in R6’s bed. Interviews conducted of residents (R1–R5) corroborated that there’s no way that would have happened here at the facility. Residents (R1-R5) have not witnessed or heard of a resident forced to sleep on the floor. Interviews conducted of Staff (S1–S4) corroborated that they were never aware of a resident forced out of their bed and made to sleep on the floor. [A review of the facility’s incident reports (July or August 2021) did not show an incident involving a caregiver having forced R6 to sleep on the floor. Facility staff confirmed that they have received in-service training on the topics of residents’ personal rights and aware that they are a mandated reporter.]

Based on the evidence gathered, interviews conducted, and records reviewed, 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 of PERSONAL RIGHTS: Resident was forced to sleep on the floor is found to be UNSUBSTANTIATED.

Based on the evidence gathered, interviews conducted, and records reviewed, 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 of NEGLECT/LACK OF SUPERVISION: Licensee failed to manage resident's incontinence resulting in UTI is found to be UNSUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), no citations were issued at this time. No exit interview was conducted as the facility closed its doors on 04/07/22 due to a change of ownership. A copy of this Complaint Report will be sent (via USPS Certified Mail) to Licensee: OAKMONT OF TORRANCE LLC; OAKMONT MGMT GROUP, LLC - 3 PARK PLAZA, SUITE 1920, Irvine, CA 92614.