It was alleged that Resident #1 (R1) requested to be placed on a 5150 hold on or around 07/16/2023, but their request was denied by facility staff which ultimately resulted in their death on 07/21/2023. An audio recording was obtained. Staff #1 (S1) was asked why R1 was not placed on a “suicide hold,” the days prior to their death and S1 stated, “I don’t know”

Interview with S1 revealed that they were working on Sunday 07/16/2023. S1 stated that R1 did say they wanted to kill themselves but did not verbalize a plan of action on how they would kill them themselves. On 07/16/2023, R1 was crying because their parent would not answer the phone, they were missing their child and had expressed displeasure with their roommate. R1 eventually reached their parent on the telephone. S1 spoke to R1s parent and advised that they had no control over room changes and that they would have to speak to the Licensee the next day. After the conversation with R1s parent, R1 mentioned to S1 “I want to kill myself.” After calming down, R1 did not exhibit or display any other behaviors. S1 stated, “after I checked on R1 that night to make sure they were okay.” S1 could not explain the “suicide hold” that is mentioned in the audio recording and stated, “R1 wasn’t talking about suicide hold,” and “parent wasn’t saying anything about suicide.” If R1’s parents said R1 was suicidal, S1 stated they would call 9-1-1 and watch over the resident. S1 called Staff #2 (S2), who is their spouse, and stated, “S2 call the Licensee to tell them what R1 said,” and S2 said that they were going to. S2 never got in contact with Licensee. When being relieved that evening, S1 told Staff #3 (S3) what R1 said about wanting to kill themselves and added, “when I left, R1 was on their bed sleeping.” S2 stated they did not receive a phone call from S1 on 07/16/2023 about R1, and added “S1 told me R1 wanted to kill themselves, to call the Licensee. I called the licensee after. The Licensee never answered the phone.” S3 could not recall if anything was relayed to them by S1 about R1 on 07/16/2023 during the shift changeover.

Licensee stated that they were not contacted by the staff for a 5150 hold for R1 and stated, “don’t remember any 5150 with R1.” They added if a resident’s condition is not life threatening, “it’s a waste. It doesn’t meet the criteria. I have to call the psych to get their opinion,” and “it’s up to our knowledge. Does it need to be hospitalized? It’s our call,” and “sometimes the residents need the attention. It’s a waste of everyone’s time. They’re sending back the same day,” and “but R1 never had a behavior problem.”

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Staff #4 (S4) confirmed working on 07/20/2023 during the NOC shift into 07/21/2023. Review of the facility records show PM medications were given to R1 at approximately 8:00 p.m. S4 described R1 as “okay,” and “fine,” at the time. The a.m. medications were given on 07/21/2023 at 7:00 a.m. and R1 did not exhibit any unusual behaviors. Staff #5 (S5) described R1 as depressed and stated that days prior to R1 death, R1 did not express to them, or any other staff members that they were in pain or needed medical assistances.

The staff working at the facility on 07/21/2023 during the a.m. shift was Licensee, S5, Staff #6 (S6), and Staff #7 (S7). Between approximately 8:40 a.m. and 11:00 a.m. R1 was on a supervised visit with their child. From approximately 12:00 p.m. to 1:15 p.m. S6 was on their lunch break. From approximately 12:30 p.m. to 1:40 p.m. Licensee and S5 were on their lunch break. S7, who is the facility maintenance personnel, was the only staff at the facility between approximately 12:30 p.m. and 1:15 p.m. S7 could not recall the last time they saw R1 alive. S6 stated when they returned from their lunch break at approximately 1:15 p.m., a resident came to the kitchen to tell them R1 was on the floor in the bathroom. Upon arrival, they observed R1 was “facing down, head down, hands on the floor.” Next to R1 body S6 found a “paper,” lighter, and a straw. S6 then called 9-1-1.

Resident #2 (R2) stated they observed R1 leave the facility’s front gate at approximately 11:15 a.m. Resident #3 (R3) stated R1” went and did some drugs,” and “collapsed on the floor. Went to the bathroom,” but could not provide any further details. Multiple other Resident interviews were conducted but no other could provide insight as to what transpired on 07/21/2023 between approximately 11:00 a.m. and 1:15p.m., other than observing R1 on the floor in the bathroom. Resident #4 (R4) stated the bathroom door was locked in the morning for a few hours, and they eventually opened the door. Resident #5 (R5) was one of the clients who found R1 on the floor and estimates R1 was in the bathroom for approximately two hours with the door locked being before being opened.

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It is unknown if R1 requested to be placed on a 5150 hold or around 07/16/2023. Licensee made it clear it is up to the facility to determine whether or not a client meets the criteria for psychiatric emergency services, or they request consultation from their contracted psychiatrist for further instructions. The facility’s action on or around 07/16/2023, did not directly contribute to R1s death five days later on 07/21/2023. If R1 was placed on a 5150 hold on 07/16/2023, they would have most likely been discharged on 07/19/2023. R1 was observed multiple times by staff and outside agencies as not a danger to themselves throughout the days leading to their death. In addition, when found unconscious on the bathroom floor, facility staff contacted 9-1-1.

Allegation: Facility is not clean, safe and sanitary and in good repair

This complaint came in October 2023. It cannot be verified whether a tour of the facility was conducted when the complaint was open. A review of the facility file indicates the facility was issued a citation regarding physical plant issues in August 2023. Interviews conducted on July 12, 2025, stated there is an insect issue that comes and goes and the staff address the issue as soon as it is brought to their attention. Also, no time frame could be established when the insect issue occurred. There hasn’t been any issues regarding physical plant issues since then. Therefore, the allegation is unsubstantiated.

Allegation: Facility staff did not provide care and supervision which resulted in illegal drug use

Licensee stated R1 attended a drug treatment program. When resident leave the facility, Licensee stated “it’s hard to control. Outside, it’s out of our control (drugs).” When Residents return to the facility, staff do not check for drugs or other outside contraband as he stated, “no, 99% don’t do drugs. Unfortunately, wrong placement. Just R1 had drug use. No one else has issues with drugs. They’re getting stable with psych meds.” Licensee stated status checks are done on the Residents during the a.m. shift and p.m. shift every hour.

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S5 classified the residents as ambulatory and just need prompting with medications. S5 denies observing R1 with drugs on their person or in their room. S5 was aware that R1 had a history of drug use and stated, “none of the residents told us she’s using.” S5 stated status checks are done on the residents in the a.m. by Licensee. Status checks are done on the residents during the p.m. shift once every hour. During NOC shift, status checks are done on the residents every 30 minutes.

S2, S3 and S4 denied residents use of drugs inside the facility. Each reported they have never seen R1 use drugs inside the facility. S4 does status checks on the residents once every 30 to 40 minutes during PM shift and S3 does status checks on the residents every 30 minutes during the NOC shift. S7 is responsible for cleaning the resident’s rooms and reported never observing drugs or drug paraphernalia while cleaning R1’s room, nor aware of drug use being a problem at the facility.

Resident #6 (R6) said they had seen R1 use drugs inside and outside of the facility. R6 did not notify any of the staff about this observation and denied other Residents use of drugs at the facility. R3 stated R1 did not do drugs in the facility and did them outside of the facility with friends. Multiple residents were interviewed and they all denied residents using drugs in the facility. Resident #7 (R7) stated, “not in here. Out in the streets. Nothing in here.” R7 also stated R1 never said they were using drugs at the facility. R5 stated they never saw R1 do drugs at the facility. R4 stated, “people don’t do drugs here. If they do, it’s a secret.”

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During supervised visit, the social worker did not observe any drugs on R1. Social worker did not see where R1 went after the visit nor did R1 mention where they were going.

Local Law Enforcement did not observe any drug or drug paraphernalia by R1 in the bathroom. During their partial walkthrough of the facility. Officers did not observe any residents using drugs at the facility.

The coroner report does indicate that R1 passed away due to Acute Fentanyl Intoxication, and Methamphetamine Present in System.

Although R1 was found with a “paper,” and a straw by S6 on 07/21/2023, residents that reside at this facility are high functioning and are allowed to leave the facility unassisted. This includes R1 as supported by their Physician’s Report that indicates they did not need constant medical supervision. Interviews with staff and residents are consistent that drug use at the facility is not a prevalent issue, and the staff are doing their due diligence in performing status checks on the clients in care.

Allegation: Facility staff failed to administer client’s medications as prescribed

Title 22 regulations does not require facilities to use a Medication Administration Record (MAR) where staff sign off they gave residents their medications. This incident occurred in October 2023. Interviews cannot verify if medications were administered as prescribed during that incident. Interviews with residents conducted on July 12, 2025, all stated they get their medications as prescribed.

Allegation: Facility lacks sufficient staff to meet the needs of the clients-

This incident occurred in October 2023. Interviews indicate there was a maintenance person working for 45 minutes while the regular caregivers were at lunch. There was no file review conducted to check to see if the maintenance personnel person had any required caregiver training. Because it cannot be verified if the maintenance person had or didn’t have caregiver training the allegation cannot be proved or disproved.

Based on interviews and records reviews, these allegations are UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated

Exit interview conducted. Licensee or administrator was advised a copy of this report will be sent via certified mail. Two copies of the report will be sent. Licensee or administrator is to sign and return a copy to the Orange County Regional Office