complaint·August 30, 2025

The investigation revealed the following: Regarding allegation: Facility staff did not notify authorized representative of incident. It is alleged facility staff did not notified R1’s responsible party regarding incidents that occurred on 5/7/25 and 6/11/25. Interviews with residents revealed facility staff notify their responsible party when necessary. Interviews with staff revealed Administrator or LVN are responsible for notifying responsible parties when incidents take place. Per administrator, on 5/8/25 administrator contacted R1’s responsible party via telephone at least three times and was unable to leave a voice message. Interview with R1’s responsible party revealed upon visiting R1 at the facility on 5/8/25, administrator stated to them that they had attempted to notify them of the bruise but had not been able to reach them. Regarding the incident on 6/11/25 responsible party called around 3:15pm and was asked to call police officer for details regarding an incident. Incident report dated 5/8/25 notes administrator notified responsible party. Incident report dated: 6/11/25 does not note responsible party was notified. Per police report reviewed, South Pasadena Police officer responded to a battery assault at the facility at 12: 32pm. Facility staff failed to notify R1’s responsible party of the incident that took place on 6/11/25 and requested to call police officer for details of the incident. Therefore, the allegation is substantiated. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted and a copy of this report, LIC 9099D, and appeal rights were provided. The investigation revealed the following: Regarding allegation: Facility staff did not provide adequate supervision resulting in a resident being attacked by another resident. It is alleged that on 5/7/25, R1 was attacked by roommate resulting in an injury. 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 behavior 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, 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. Incident report review does not show a history of aggressive behavior’s observed of R2 in the last 2 years. Review of police report and video, it was observed that R2 drags R1 to the floor causing R1 to hit the side of the head against the rail and two staff respond to assist R1. 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 occur. However, The facility took action once the first incident happened 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. Exit interview was conducted and a copy of this report was provided.