Complaint·June 20, 2024

During the course of the investigation, Investigator Ferris obtained copies of the following documents pertaining to Resident 1 (R1): Physician’s Report For Residential Care Facilities for the Elderly (RCFE) (LIC602A) dated 06/20/23 and 08/09/22, two (2) Unusual Incident/ Injury Reports (LIC624) dated 07/10/23 and 04/21/23, Resident Appraisal (LIC603A), Preplacement Appraisal Information (LIC603), Facility Communication Notes, Identification and Emergency Information, Appraisal/ Needs and Services Plan (LIC625) dated 05/01/19, Kaiser Permanente Hospital Records, and Los Angeles Fire Department Care Report dated 07/07/24. Investigator Ferris interviewed Facility Administrator Anna Rempel, facility staff (S1-5), facility Residents 1-2 (R1-2), R1 Family Member (R1 FM1) and Gateways Conditional Release Program (ConRep) Clinical Director (W1). The investigation revealed the following: Regarding allegation of, Staff neglect led to serious hospitalization of resident , during this investigation, the Department of Social Services Investigation Bureau, Investigator Ferris, reviewed hospital records which revealed that R1 was hospitalized due to an ongoing medical diagnosis and complications that resulted from it. Hospital Records revealed that R1’s hospitalization was not a result of neglect/ lack of supervision. Investigator Ferris stated that there was insufficient evidence to support the allegation of Neglect/ Lack of Supervision led to R1’s hospitalization. Based on the investigation and supporting information obtained, this allegation is not corroborated. For allegation, Staff did not seek timely medical attention for resident, during this investigation, the Department of Social Services Investigation Bureau, Investigator Ferris, interviewed facility administrator and S1-5 and their statements revealed that R1 was provided adequate and timely care and they were unaware that R1 had recently fell. Administrator stated that R1 had one fall on 04/20/23 while they were outside of the facility and that there were no reports of R1 falling since then. Administrator stated that R1 will let staff know when they need to see or speak to their doctors and had not requested to go to the hospital. Administrator stated that R1 was hospitalized on 07/07/23 due to observation of resident being weak. Interview with R2 who is R1’s roommate revealed that they did not see R1 fall or see R1 on the floor and only heard a noise that sounded as if R1 had fallen. R2 stated that R1 did not mention they had fallen, and that staff checked on R1 and then sent R1 to the hospital. R1 stated that they did not recall what happened prior to their hospitalization and did not recall falling off the toilet or anywhere else. R1 stated that R1 FM1 told them that they had fallen. R1 stated that they like the facility but that R1 FM1 does not like the facility as they believe that R1 is not getting adequate care. R1 stated that R1 FM1 has not visited them at the facility as they live out of state. R1 stated that staff would send them to the hospital if they had a fall. R1 stated that they do not have any concerns with the facility and that staff provided a good level of care and supervision. R1 additionally stated that they were treated well at the facility, they were never mistreated or neglected by facility staff. R1 stated that staff had never denied them medical attention when needed or requested. R1 stated that they would return to the facility when possible and felt that the facility was safe for them and other residents. Based on interviews conducted with facility staff and R1-2 there is insufficient evidence to support the allegation, this allegation is not corroborated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview held. A copy of the report was provided to Administrator Anna Rempel.