complaint·October 30, 2023

The investigation revealed the following: Allegation: Due to lack of supervision, resident got into a physical altercation with another resident. On 10/30/23, LPA spoke with Administrator at 10:30am she stated on 10/4/23 at 5am there was an altercation happen between two parties and the police department was called. On 10/30/23 at 10:30 am , LPA Shirley interviewed resident 1 – resident 10 (R-1 - R-10). LPA asked, “Have you ever gotten into a physical altercation with another resident”. of those interviewed, nine out of ten residents interviewed replied in the negative. LPA asked residents had you ever had a situation/altercation and staff was not available to assist you. Of those interviewed, nine out of ten answered no, there has never been a situation/altercation that staff was not there to assist them. On 10/30/23, at 12:00pm LPA Shirley interviewed staff 1 – staff 9 (S-1 - S-9). LPA asked if there had been any physical altercations with resident against another resident. Based on interviews 3 out of 9 staff interviewed stated that yes there was an incident that occurred on 10/4/23 with two residents that was reported to the administrator. On 10/30/23, at 11:15am LPA reviewed facility files. During file review, LPA found that resident visited Gardena Memorial on 10/4/23 and 10/5/23 for upper extremity pain. LPA also observed unusual incident/injury report and SOC 341 dated the same date as the incident that was reported by resident. Based on interviews and information gathered, this incident happened on 10/4/23 at around 5am, S-5 heard the commotion and intervened in the situation between the two residents and contacted Administrator. One resident elected to be taken to the hospital, the other resident chose to be patched up by ambulance but later called 911 to be transported to Gardena Memorial Hospital. Based on interviews conducted and records reviewed there is insufficient evidence to support the allegation: Due to lack of supervision, resident got into a physical altercation with another resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation are Unsubstantiated. Exit interview was conducted and a copy of this report was provided to the Administrator Susie Fuentes.