complaint·December 18, 2025

During today’s visit, the LPA and Staff conducted a physical plant tour at 11:27AM, and no immediate concerns were observed. The following was then determined: Allegation: “Staff do not treat resident with respect” It was reported that on 10/23/2025, Staff #1 (S1) spoke inappropriately and shouted at Resident #1 (R1). Specifically, S1 allegedly directed R1 to clean up used cigarettes in the rear yard. R1 complied and attempted to dispose of the cigarettes in the garbage bins located on the driveway outside the facility gate. During this time. S1 reportedly insulted R1; however, no specific examples of insulting language were provided. Interview with S1 revealed that S1 did not instruct R1 to clean their cigarettes but instead inquired about a pack of cigarettes left the day prior, with the intention of returning it. R1 responded that the pack did not belong to them and then proceeded to answer the rear gate for an unknown individual approaching the facility. S1 explained to R1 that visitors are not permitted entry through the rear yard and must enter through the front door. R1 then indicated they needed to access the garbage bins, at which point Resident #2 (R2) intervened. R2 confirmed that S1 did not instruct R1 to clean up and reported that no shouting or demeaning comments occurred. R2 further explained that R1 attempted to exit the rear gate to access the garbage bins, but R2 reminded R1 that a trash/ash tray was available on the patio table for cigarette disposal. Resident #3 (R3) noted that staff can sometimes be perceived as carrying themselves with a negative attitude, while R2 and Resident #4 (R4) described staff as respectful. R1 also acknowledged that two (2) out of three (3) staff are respectful. Observations of staff interactions did not reveal yelling or mistreatment of residents. S1 acknowledged the importance of their role and expressed a commitment to ensure they speak to residents calmly and respectfully. Report Continued on LIC 9099-C The Administrator reported awareness of staff’s cultural presence, which may occasionally be perceived negatively, and confirmed that the facility conducts regular in-service training on Cultural Diversity and Effective Communication Skills, with the most recent training held on 10/25/2025. Subsequently, Resident Personal Rights training was conducted on 10/27/2025. It was additionally reported that facility staff and the Administrator badgered R1 upon receiving information about R1 relocating facilities. S1 stated they were unaware of R1’s relocation until they overheard R1 speaking with R2, at which point, R1 subsequently was transferred to the hospital the same day. Phone records indicated that R1 continuously called the facility and Administrator several times a day while they were at the hospital and Skilled Nursing Facility (SNF). The Administrator and S1 reported R1 calling to update them about their hospital visit and requesting if they could return to the facility. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. Allegations: “Staff did not ensure resident was safe while having a seizure” and “Staff did not get timely medical care for resident.” It was reported that facility staff failed to assist R1 during seizure episodes and refused to provide medical services. R1 was admitted on 08/22/2025 and initially experienced seizures approximately every two (2) weeks. On 10/15/2025, R1 reported an increase in frequency, occurring every other day to nearly daily, sometimes multiple times per day. On 10/23/2025, staff allegedly refused to contact Emergency Medical Services (EMS) despite R1 experiencing five (5) to six (6) seizures that day. R1 stated that staff observed their seizures but did not intervene or check on them afterward and further reported unwitnessed seizures to staff. Report Continued on LIC 9099-C According to R1, staff were trained to call EMS if two (2) to three (3) seizures occurred in one (1) day and to provide safety measures such as turning R1 to their side, elevating their head, and monitoring them afterward. On 10/23/2025, R1 called EMS independently and reported multiple seizures. R1’s Case Worker also recommended EMS for transfer to a Skilled Nursing Facility (SNF). EMS dispatch requested address verification, during which S1 denied that R1 had experienced seizures that day. Interview with S1 and the Administrator revealed that R1 did not consistently disclose seizures, and staff frequently inquired to monitor R1’s condition. They reported that R1 often stated they had no seizures or experienced one (1) seizure every three (3) to four (4) days. S1 stated they had observed one (1) seizure and followed protocol by removing obstructions, turning R1 to their side, and continued monitoring. Staff explained that R1’s Home Services Care Plan required EMS contact if R1 had more than three (3) seizures per day. Staff reported this threshold was not met as Staff did not observe and R1 did not report multiple seizures in a day. S1 also noted that a Physician adjusted R1’s medications which reportedly reduced R1’s seizure frequency. Interviews with other residents provided limited corroboration: R2 did not observe seizures, while R3 reported seeing one (1) episode through R1’s doorway. During this time, R1 was seen unsuccessfully attempting to call for help. Staff checked on R1 after the seizure concluded and continued monitoring. Record review included a Physician’s Report dated 08/11/2025 which documented a diagnosis that included Lennox-Gastaut Syndrome, Developmental Delay, Traumatic Brain Injury, and Bipolar/Schizoaffective Disorder. It was also noted that R1 faced forgetfulness to take their medication and with daily support R1’s seizures and mental health conditions will improve and subsequently improve their quality of life including reduction in seizures. Medication Administration Record review documented R1 received all prescribed medications. R1’s Appraisal/Needs and Services Plan and Enriched Residential Care Services Need and Tier Assessment indicated that R1 would benefit from medication management, assistance with activities of daily living during exacerbation of seizure symptoms, and overall seizure symptom management. Report Continued on LIC 9099-C In addition to providing Staff seizure precautions, Home Care Services instructed Staff to call 911 if R1’s seizures last more than five (5) minutes, R1 does not return to consciousness, if another seizure begins before R1 regains consciousness, and if R1 injured themselves after the seizure. Skilled Nursing Visit Notes on 10/08/2025 documented R1 reporting having one (1) seizure lasting five (5) seconds. Additionally, Staff were instructed to call EMS if R1 experienced three (3) seizures a day. On 10/15/2025, R1 reported zero (0) seizures and on 10/22/2025, reported two (2) episodes throughout that week. R1 reported each time they were safe, and Staff checked on them frequently and did not have any concerns. Los Angeles Fire Department (LAFD) Patient Care Report on 10/23/2025 indicated EMS arrived on scene at 12:46PM, noted R1 approached the ambulance appearing in no distress, and reported seizures on prior days but none that day. R1 requested Physician evaluation and was transferred to the hospital without complications. Based on interview and record review, R1’s statements varied and were not consistently corroborated by Staff, Residents, or EMS and Home Care Services documentation. Staff reported fewer seizures and adherence to seizure protocols, and records confirmed medication compliance and Physician oversight. Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violations did or did not occur, therefore the allegations are deemed UNSUBSTANTIATED at this time. Due to the Administrator’s unavailability, verbal confirmation was received for Staff to sign today’s report. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.