complaint·August 5, 2025

Interviews conducted with residents revealed 4 out of 5 residents stated not have observed R2 having aggressive behaviors, hearing an argument, loud noises, or being hurt by R2 at the facility. 1 out of 5 residents stated R2 hit resident with an open hand in the face seven times the evening of 5/7/25. Interviews with staff determined staff did not observe or hear loud noises that indicate the incident was happening. Staff stated that on 5/8/25 LVN noted the bruise around the eye when providing eye drops in the morning. Per staff, R2 has not shown aggressive behaviors in the last six months, other than the one incident they observed in the dining room on 6/11/25. Documents reviewed revealed; incident report dated 5/8/25 notes R1 was observed with a bruise in the eye and R1 stated that it was due to R2 hitting R1. R1 was provided with first aid assistance, R1’s responsible party was notified, and R2 was transferred to a different room. Incident report dated: 6/11/25 notes R2 was walking behind R1 in the dining room and pulled R1’s hair causing R1 to fall. The administrator contacted South Pasadena Police Department and police report was created. R2’s physician’s report does not note aggressive behaviors. Although R1 had a bruise on 5/8/25 it is unsure if R2 caused the bruise, and the incident on 6/11/25 did happen. The facility took action once the first incident and moved R2 to a different room. During the second incident Administrator contacted South Pasadena Police Department and sought care for R1 and R2. Therefore, the allegations is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Regarding allegation: Facility staff did not notify authorized representative of incident . It is alleged facility staff did not notified R1’s responsible party regarding incident that occurred on 5/7/25. Interviews with residents revealed facility staff notified their responsible party when necessary. Interviews with staff revealed Administrator or LVN notify responsible party when incidents take place. Per administrator, on 5/8/25 administrator contacted R1’s responsible party phone number at least three times and was unable to leave a voice message. Interview with R1’s responsible party revealed upon visit administrator had stated to them that they had attempted to notify them of the bruise but had not been able to reach them. Incident report dated 5/8/25 notes administrator notified responsible party. Although the administrator may not have reach R1’s responsible party. It was noted on incident report dated 5/8/25 that they contacted the responsible party. Therefore, this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview was conducted with Lydia Pabion and a copy of this report was provided.