complaint·March 4, 2024

Based on interviews conducted and records reviewed, it was discovered that residents R1 and R2 were able to ambulate inside and outside the facility independently. Additionally, staff confirmed residents could be in the patio area unsupervised. The review of the surveillance footage revealed R1 assaulted R2 with an object (ashtray pole) on 10/21/2023 at 0851 hours. The review of the EMS and 911 audio all revealed Los Angeles County Fire Department was dispatched to the facility at 0859 hours, approximately eight minutes after the incident. The facility staff interviewed revealed R1 had not displayed aggressive behavior towards staff/residents and had no prior incidents. The interview of facility staff confirmed R2 and R1 were separated and assessed. Emergency medical services were requested, and law enforcement was notified of the incident. Based on interviews, and file review the investigation revealed: 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 is UNSUBSTANTIATED. Exit interview conducted with Gemma Deoso and a copy of this record provided.