complaint·July 21, 2025

Allegation: Staff did not prevent resident from engaging in verbal altercations with other residents. It was reported by Resident #1 - R1 that there was an incident back on January 3 rd 2025, where R1 got involved in verbal altercation with R2. To investigate the allegation, during today’s visit, LPAs interviewed the General Manager, four (4) staff/caregivers, and nine (9) out of ninety-six (96) residents residing at the facility. LPAs also reviewed R1 and R2 files, incident reports, and facility internal investigation reports. Interviews with staff members confirmed that a verbal interaction occurred between two residents (R1 and R2) on February 3rd 2025, and they described the situation as a brief verbal disagreement near the elevator area. Staff were immediately alerted to the situation and responded promptly. They separated the residents, de-escalated the interaction, and ensured that both parties were safe and calm. The management followed the internal procedures by documenting the incident, notifying appropriate parties, and facility driver transported R1 to UCLA West Valley Medical Center - ER for evaluation, as R1 mentioned that during the verbal altercation R2 swung the empty canvas bag, did not hit R1, however, R1 wrenched the right side of the body and was in pain. Staff continually monitored both residents R1 and R2 for any signs of distress or further conflict. Interviews with residents confirmed that the staff presence and intervention are always timely and appropriate. No evidence of negligence or lack of supervision observed during today’s visit on the part of the facility staff. Residents also denied of witnessing or observing any ongoing issues between residents residing in the community and stated that they feel safe and supervised at all times. Although, the verbal altercation did occur between R1 and R2, staff responded immediately and intervened appropriately to manage the situation. Therefore, based on interviews, records review and observation, the allegation that staff did not prevent a resident from engaging in verbal altercation with other resident is Unsubstantiated at this time. Continue on LIC9099-C Allegation: Staff are not providing a comfortable environment for residents. It was reported by R1 that there was an incident back on January 3 rd , where R1 got involved in verbal altercation with R2. R1 also reported that about four to six (4-6) weeks ago R1 had scabies and that R1 was told by the facility’s attorney that R1 brought the scabies in through his/her parakeet. To investigate the complaint, LPAs interviewed the General Manager, four (4) staff/caregivers, and nine (9) out of ninety-six (96) residents residing at the facility. LPAs also reviewed R1 and R2 files, incident reports, and facility internal investigation reports. In course of the investigation, interviews and review of medical records confirmed that Resident #1 (R1) had reported skin condition in March 2024, described a rash on their body. R1 was assessed by dermatologist, who confirmed that the rash was diagnosed as scabies. Upon receiving the diagnosis, the facility staff took immediate and appropriate action in line with infection control protocols. R1 and R1’s spouse who also resides in the same room were temporarily isolated to prevent the possible spread. Both residents received prescribed medication treatment as ordered by the physician. There were no additional reports of skin rash or scabies symptoms among other residents or staff members before or after the incident. Staff members also confirmed that enhanced cleaning and sanitizing procedures were conducted. Interviews with multiple residents indicated they feel safe and comfortable in the facility. Residents reported satisfaction with the living conditions and the attentiveness of the staff. All residents interviewed denied of ever having skin rash or scabies while residing in the facility. Observations made during the facility visit showed a clean, well maintained, and welcoming environment. No evidence was found to support the claim that the environment is not conducive to resident comfort. Based on the information obtained through interviews, documentation review, and on-site observations, there is insufficient evidence to support the allegation of staff failing to provide safe environment for residents. Therefore, the allegation listed above is deemed Unsubstantiated at this time. No deficiency cited during today’s visit. Exit interview conducted, copy of the report delivered.