complaint·January 11, 2024

Continued from 9099 Investigator Ferris conducted interviews on 10/03/2023 with the Executive Director/Administrator, R1, other residents and staff. Additional interviews with staff were also conducted on 10/23/2023. On 09/27/2023, Investigator Ferris reviewed Los Angeles County Fire Department report incident #0801 and on 10/17/2023, Investigator Ferris reviewed medical records from Providence Tarzana Medical Center. The Investigation revealed that on 09/03/2023, R1 pulled the emergency cord in their bathroom. Staff #(S1) arrived to R1’s unit to find R1 unconscious. S1 requested assistance from Staff #2 (S2) and Staff #3(S3). 9-1-1 was called while S2 was on their way to R1’s unit. As both S1 and S2 attempted to relocate R1 to the floor, Paramedics arrived and began to conduct Cardiopulmonary Resuscitation (CPR). S3 entered the unit as Paramedics arrived. Interviews with S1, S2, S3 and records review revealed that S1, S2, S3 and Paramedics each stated they did not observe any drug paraphernalia present near R1. Interviews conducted and records review of R1’s resident records further reflected that R1 is independent and comes and goes from the facility without assistance. R1 stated they “found” a foil package containing a “substance” while outside of the facility and brought the foil package and substance into the facility. R1 said without anyone’s knowledge, R1 decided to “smoke” what was in the foil package. Per R1, staff did not know R1 found the foil package containing a substance, did not know R1 brought a substance into the facility, and did not know R1 intended to smoke what R1 found. Per Administrator Rose Anguiano, R1 is independent, does not have 1:1 care, leaves the facility unassisted and no resident is searched upon entering the facility after leaving. Rose stated they had no knowledge R1 was in possession of any substances or going to use any substances, though via the resident’s contracts, it is against the rules to have any illegal substances on the premises. Per staff interviewed, they denied having any knowledge that R1 was in possession of any substances or that R1 was going to use any substances. R1 also did not advise anyone they had any illegal substances. Per Providence Cedar-Sinai Tarzana Medical Center records, R1 tested positive for cannabinoids and fentanyl. Based on information obtained, the investigation did not provide sufficient evidence to substantiate neglect/lack of care against Administrator Rose Anguiano. Therefore, the above allegations, “staff failed to provide an adequate level of care resulting in R1 overdosing” and “staff failed to provide care resulting in illegal drugs being present on the premises” have been Unsubstantiated at this time. Exit interview conducted and a copy of report issued.