complaint·July 1, 2025

Page 2. On 02/05/2025, from 10:05am to 12:45pm, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced initial visit to investigate the allegation listed above. LPA Urena was greeted by staff and informed of the visit. The staff contacted the Administrator Ovsanna Khayalyan via telephone to inform them of the visit. The Administrator arrived at 10:45am and the LPA explained the reason for the visit. The LPA requested records pertinent to the investigation at 10:55am and interviewed the Administrator from 11:09am to 11:57am. The Administrator was advised that the complaint was referred to the Investigations Branch (IB); however, an IB investigator had not yet been assigned as of the visit date. The LPA determined further investigation was needed prior to issuing findings. On 02/24/2025, at approximately 11:55am, Investigator Real conducted interviews with Kaiser Permanente Hospital Social Worker; on 02/25/2025, from approximately 8:45am to 12:30pm, with County of Los Angeles Deputy Public Guardians; on 03/14/2025, at approximately 11:00am, with facility resident; on 04/15/2025, from approximately 10:00am to 1:00pm, with Staff #1 (S1), Administrator, and facility residents; on 05/22/2025, from approximately 11:45am to 1:15pm, with Los Angeles Police Department (LAPD) Detective and Sunshine Care Hospice Administrator; and on 05/29/2025, at approximately 12:00pm, with Sunshine Care Hospice Registered Nurse. In addition, Investigator Real reviewed Kaiser Permanente Hospital medical records, Los Angeles Public Guardian (LAPG) conservator court documents, Sunshine Care Hospice Records, and facility file documents related to the investigation. Due to the complaint was not reported to the LAPD as a crime report, a police report was not generated. Therefore, no investigation or interviews were conducted by the LAPD. According to R1’s Physician’s Report, dated 07/29/2024, the report indicated R1 was diagnosed with Type II diabetes, atrial fibrillation, hypertension, and dementia. R1 was noted as having lower leg diabetic wounds. R1 was admitted to the facility on 07/30/2024. Continues on LIC 9099C page 3.... Page 3. A review of the Sunshine Care Hospice records revealed on 11/30/2024, R1 was placed on hospice with the primary diagnosis of Unspecified Protein-Calorie Malnutrition and the Secondary diagnosis as Senile Degeneration of the brain. The hospice certification period was listed as 11/30/2024 to 02/27/2025. Frequency of visits was noted as home aide 2 times per week, LVN 1 time per week, and RN every 2 weeks. The Department’s investigation revealed R1 was under hospice care while residing in the facility and hospice was aware R1’s health was declining. According to R1’s hospice nurse, they saw no evidence to suggest that R1’s decline in health was due to neglect or abuse by the facility and believes R1’s decline was due to advanced dementia and possibly other comorbidities. R1’s hospice nurses instructed the facility caregivers to turn R1 every two hours, and the hospice nurse had no reason to believe the facility staff did not do so. R1 had a very poor appetite and frequently refused to eat or drink. This behavior likely contributed to R1’s skin breakdown leading to the unstageable pressure injury and the beginning of injuries on R1’s feet. Wound care was ordered through hospice to address the skin breakdown issues and an initial wound assessment was done on 01/29/2025, the day prior to R1 being sent to the hospital. The facility staff denied the allegation and reported turning R1 every two hours as instructed by hospice. The information obtained during the Department’s investigation did not sufficiently support the allegation. While R1 did sustain pressure injuries during their stay at the facility, the investigation did not provide sufficient evidence to substantiate neglect/lack of care. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.