1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32 | Allegation: Questionable death. The complaint alleges that on August 15, 2025, at approximately 6:46 AM, a medication technician found resident (R1) deceased in their room after sustaining a fall. The resident was found unresponsive laying supine on the floor with their head/neck area on the TV stand, blood present on the mouth, floor, back of head, and on the floor. LA County Fire Department arrived on scene and pronounced the resident dead. An injury was noted on the back of the decedent's head. The Department of Social Services Investigation Branch obtained the County of Los Angeles Medical Examiner Death Investigation Summary and Death Certificate. The cause of death was deemed accidental/natural. Per record review, R1 had mild cognitive impairment, used a quad cane, was independent in mobility/transfer, was not a fall risk, and there were no observable safety awareness deficits. The findings indicate there is insufficient evidence to corroborate the allegation.
Allegation: Staff does not serve residents meals on time. It is alleged that in August 2025 residents were being served meals late and residents were complaining about being hungry. On 8/28/25, five residents were interviewed. The residents said their meals were now being served on time, but acknowledged that in the month of July 2025 there was delays in meal serving times. Three staff were interviewed on 8/28/25, whom stated that the dining services department had been short staffed for approximately 2 months, thus meals were served late at times, and the Dining Services Director asked caregivers to help serve residents meals. The kitchen was toured, and on that day there was sufficient staffing in the dining room and meals were served on time. During today's visit, 3 additional residents and 2 additional staff were interviewed. The findings indicate that during Summer 2025 there were kitchen staffing shortages that affected meal times. Based on interviews and record review, this allegation was investigated in July 2025 and already substantiated under complaint, control # 28-AS-20250716151740.
Allegation: Staff are not providing residents assistance in a timely manner. It is alleged that the residents laundry was "backed up" and some residents did not have any clean clothes or linens. A total of 5 staff were interviewed, of which all stated that all residents clothes was being washed as required. According to interviews, during Summer 2025 there were 3 housekeepers on the day shift, but towards the end of August 2025 a fourth housekeeper was hired. Five residents were interviewed on 8/28/25, all stated their clothes is washed regularly and reported no laundry issues. On 8/28/2025, LPA toured the laundry rooms. The laundry machines were operable and residents clothes was being washed. No large piles of resident's clothes and linens were observed in the laundry rooms. During today's visit, LPA checked all 3 laundry room areas and did no observe backed up laundry. The residents and staff interviewed today denied the allegation. Therefore, there is insufficient information to support the allegation.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was discussed and provided to Executive Director Colleen Rozatti. |