complaint·May 28, 2025

Page 2. prior to issuing findings. No health and safety concerns noted on today’s visit. Exit interview conducted. No citations issued at this time. A copy of the report was issued On 4/24/25, Licensing Program Analyst (LPA) Christine Yee conducted a subsequent unannounced complaint visit to investigate the above allegation and met with Dion Gallarza, Executive Director. The reason for the visit was explained. On today's visit, LPA Yee conducted another interview with the Executive Director at 10:21am, Resident #2 at 11:15am, Staff #1 at 11:36am, Staff #2 at 11:52am, Staff #3 at 12:19pm, Staff #4 at 1:52pm, conducted a tour of the site of the incident at 1:25pm and obtained additional facility documents throughout the visit. Per interviews and documents reviewed during today's visit, it was again determined that additional investigation is needed before the findings of the above allegation can be made. Per the investigation conducted regarding the allegation of questionable death of Resident #1, the following information was revealed. Resident #1 was admitted to the facility on 6/8/2024. Per review of the Physician’s Report dated 5/22/24, Resident #1 was diagnosed with bipolar disorder, anxiety disorder, polymyalgia rheumatica and had mild cognitive impairment. Per interview with Witness #1, Resident #1 was not on any medications for bipolar disorder or depression when they became a client of theirs. Resident #1 had a known history of depression and was previously prescribed lithium, a mood stabilizer for bipolar disorder but it was discontinued when the resident was hospitalized for lithium toxicity. Lithium was not resumed after the hospitalization. Records reviewed also do not indicate any history of suicidal ideations. At the time of admission, Resident #1 was not on any psychiatric medications. The Physician’s report Page 3. also indicates that Resident #1 is not currently depressed. Per interview conducted with Witness #1, Resident #1 was not on any medications for depression or bipolar disorder when Resident #1 became a client of theirs in February 2024. Witness #1 also indicated that they do not treat mental disorders as it is outside their scope of practice. The family was advised to take Resident #1 to see a mental health professional or to return to the doctor who had prescribed the Lithium initially. On 9/13/24, the resident’s family took Resident #1 to their doctor appointment and on that visit the resident was observed to be very restless and was prescribed Escitalopram 5mg to treat their anxiety. Per facility records, the medication was started on 9/17/24. On the afternoon of 9/29/24, Resident #1 was found lying face down on the ground in a pool of blood by Resident #2. Resident #2 was returning to their room from the back of the building. Resident #2 returned to their room and called the front desk for assistance. Staff #1 was sent to assist Resident #2, but it was unclear whether it was Resident #2 that needed help. Per Staff #1, they went to Resident #2s room, also using the back way and found Resident#1, unresponsive and laying face down in a pool of blood. The front desk was contacted to call 911. Staff #4 called 911 and was asked to turn Resident #1 over and perform CPR. Staff #1 assisted Staff #4 with turning the resident over and chest compressions were administered by Staff #4 until the paramedics arrived to take over. The paramedics pronounced the time of death at 1324 hours. Once the paramedics were done, the police cordoned off the resident’s room and the back area as a crime scene to conduct their investigation. Per their investigation, Page 4. Resident #1 was last seen by Staff #1 at 1200 hours on 9/29/24. The police observed that Resident #1 was laying on their back. Per interview conducted with Staff #1, police were informed that Resident #1 was initially found unresponsive, facing down. Per the police investigation, Resident #1 was found on the ground directly below the second-floor landing. Police also found a sandal belonging to the resident by the railing on the second-floor landing. Based on these observations, it was determined that Resident #1 fell from the second floor and determined that the resident committed suicide. There was no suicide note found. The police also contacted the coroner on the day of the incident. Upon arrival at the scene, the coroner took over the investigation from the police. Upon completion of their investigation, Resident #1 was transported to the LA County morgue due to the circumstances of the death. Resident #1 was examined on 9/30/24 and cause of death was noted as multiple blunt force trauma injuries and the manner of death is suicide. Per police interview conducted with the family, they were given the same information that was given to LPA Yee on 11/5/24 by the family member that was interviewed. The family mentioned that Resident #1 had threatened to do harm to themselves. The family member indicated that they had no reason to take these threats seriously as there was no prior history of suicidal attempts. LPA Yee was not specifically told by family member how Resident #1 was going to hurt themselves. When family was told that Resident #1 fell from the second- floor stairwell landing they suspected that Resident #1 had jumped as they threatened to do. The threats made by Resident #1 to hurt themselves to the Page 5. family was never mentioned to facility staff to allow them the opportunity to seek help for the resident or implement precautionary measures to mitigate any harm to the resident. Per interviews conducted with Staff, they all stated that the resident was observed to be happy. Resident #1 was sociable to staff and residents and was beginning to make friends. Staff did not observe the resident to be depressed or showed any change in condition to raise concerns. Based on LPA Yee’s investigation, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. Unless the Department obtains new evidence to change the finding of the investigation, the allegation of questionable death is unsubstantiated at this time. No deficiencies were cited on today's visit Exit interview was conducted and a copy of this report was provided.