From 11/18/2024 – 11/20/2024 LPA and North Los Angeles County Regional Center (NLACRC), Quality Assurance Specialist (QAS) Lisseth Carrillo corresponded via email and on 11/20/2024 at 3:00p.m. corresponded via video chat. On 05/30/2025 starting at 10:08 a.m. LPA Mosley conducted an unannounced subsequent complaint visit, an entrance interview and a brief physical plant tour were conducted to ensure there are no immediate health and safety concerns, and facility is in compliance with Title 22 Regulations. At 11:57 a.m. conducted an in-person interview with a staff member, at 12:12 p.m. conducted a telephonic interview with a former staff member and collected copies of pertinent documents relevant to the investigation. In relation to another investigation conducted on 10/15/2024, on 10/23/2024 LPA subpoenaed hospital records from both hospitals where Resident #1 (R1) was hospitalized. On 11/05/2024 and 01/27/2025 received hospital records. Additionally, on 11/22/2024, Investigator Flores obtained a copy of R1’s death certificate.

During today’s visit, starting at 11:32 a.m. LPA conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns and facility is in compliance with Title 22 Regulations.

On the allegation QUESTIONABLE DEATH, it is the concern of the reporting party (RP) that facility staff did not properly care for Resident #1 (R1) resulting in death. To investigate this complaint, LPA conducted in person interviews, telephonic interviews, file and record review corresponded via email and video chat, obtained copies of pertinent documents relevant to the investigation.

Interview with the Administrator revealed that staff were monitoring R1’s residuals to assess digestion via their G-tube. Feedings were withheld on three (3) occasions due to residuals exceeding 100cc. R1’s PCP was contacted following the first incident and advised staff to adhere to the prescribed dietary orders. On 10/02/2024 at approximately 2:00 a.m., R1 was sent to the hospital after the night nurse observed that R1 appeared pale and had an oxygen saturation level of 87%. CPR was initiated due to a low pulse, and 911 was called. R1 was transported to Hospital #1 (H1) and admitted for respiratory failure. Intubation attempts were unsuccessful, and R1 experienced a gastrointestinal bleed. R1 was subsequently placed on high-flow oxygen. Additionally, the Administrator reported receiving only one (1) update from H1. Despite repeated follow-up calls, no further information was provided due to lack of authorization. As of 10/16/2024, no additional updates had been received from H1. Report continued on LIC 9099-C PAGE 3...

Prior to hospitalization, it was noted that RPR1 expressed concerns regarding R1’s body temperature and lethargy during a visitation. However, vitals were normal at the time, and R1 was observed to be active with staff. On 10/23/2025, the Administrator was informed that R1 had passed away. The Administrator went on to say the facility and its staff have consistently provided excellent care and supervision for all clients, including R1. In the period leading up to R1’s passing, the facility fulfilled all necessary responsibilities to ensure the safety and well-being of its residents.

Staff interviews revealed that R1 was under one-to-one supervision and consistently monitored. On 10/03/2024 at approximately 2:00 a.m., R1 was transported to the hospital after staff observed concerning symptoms and called 911. R1 was admitted in critical condition. R1’s one-to-one staff provided support in the ICU and checked on R1 periodically. During the week of 10/03, staff observed that R1 was not acting like themselves. R1 did not eat, urinate, or have bowel movements on Monday, 09/30, and Tuesday, 10/01. R1 remained lethargic through Wednesday, 10/02, and Thursday, 10/03. Despite these changes, R1’s vital signs remained within normal limits and were closely monitored by nursing staff.

Records review revealed that Resident #1 (R1) was admitted to the facility on 08/05/2020 and expired on 01/16/2024. A physician’s report dated 02/29/2024 indicated that R1’s primary diagnosis was PID, secondary to Cornelia de Lange syndrome and cerebral palsy, with additional diagnoses including PICA, constipation, GERD, and unspecified uncomplicated asthma. R1 was non-ambulatory, followed a special diet, and exhibited bowel, bladder, and motor impairments. R1 was frequently confused but able to communicate needs and occasionally follow instructions. According to R1’s assessment dated 09/30/2024 R1 primary diagnosis of sever intellectual disability with vitals at HR: 123, RR 20, O2sat 100% with clear lungs. Good skin color moist and intact. No signs or symptoms of raspatory distress or SOB. No emesis or PRN’s noted.

R1’s incident report revealed that on 10/03/2024, R1 was sent to the hospital at approximately 2:00 a.m. after the night nurse observed that R1 appeared pale. Vital signs were checked, revealing a present pulse and oxygen saturation at 71%. Oxygen was administered per physician’s orders, and 911 was called. CPR was initiated as directed by paramedics, and R1 was transported to Hospital #1 (H1).

R1’s death certificate confirmed that R1 expired on 10/19/2024 due to Acute Hypoxic Respiratory Failure, with underlying congenital conditions including Tracheomalacia, CHARGE syndrome, and cerebral palsy.

Report continued on LIC 9099-C PAGE 4..

Record review showed that on 10/02/2024, facility staff communicated changes in R1’s condition to the primary care provider (PCP) office via email, with a response time between 5–7 hours. However, there was no documentation indicating that the home RN was notified regarding the change in condition for assessment and care plan development. Consumer notes revealed that R1 had daily staff documentation across AM, PM, and NOC shifts, detailing visitors, phone calls, important reminders for the next shift, hygiene, meals, medications, daily activities, medical/dental visits, and summaries of body checks for injuries. Hospital records confirmed that R1 had a complex medical history, including cerebral palsy, Cornelia de Lange syndrome, CHARGE syndrome, GERD, asthma, and G-tube dependence, and was admitted due to hypoxia and cardiac arrest.

A review of the North Los Angeles County Regional Center Corrective Action plan dated March 5, 2025 , and the Department of Developmental Services Summary of DDS Semiannual Review Findings and Recommendations related to R1 dated August 17, 2025 and the April 22, 2025 and October 29, 2024 ARFPHSN Semi Annual Review Protocol was also conducted.

Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of QUESTIONABLE DEATH is deemed unsubstantiated at this time.

No deficiencies were observed or cited during today’s inspection. Exit interview conducted. Report was reviewed and a copy was provided.