complaint·August 18, 2025

Regarding allegation: Staff do not prevent resident from wandering into other residents room resulting in verbal altercations. It was alleged that R2 entered R1's room without being invited and will refuse to leave, and then R1 threatened R2 to leave while holding a fork in her hand. Based on interviews conducted it was revealed that there are some residents that wander at the facility and R2 is one of them. R2 walks around the whole facility and goes to residents rooms sometimes if residents doors unlocked. Facility staff always encouraged residents to keep their doors closed to prevent other residents entering their rooms. Interviewed staff stated that since R2 was admitted to the facility, R2 thinks that the facility is their home and trying to enter every room and wants everyone to leave her/his house. Interviewed staff stated that they aware of R2's behavior and R2 always supervised by staff as well as others. Staff always redirect R2 when R2 is confused. On 08/13/25 R2 entered R1's room and refused to leave. Interviewed S6 stated that they heard loud voices from R1's room and rushed to R1's room. S6 saw that R1 screaming and telling R2 to leave the room. S6 stated that R1 was confused and taught that he/she was in his/her room telling R1 to leave the room. S6 redirected R2 out of R1's room. S6 stated that they didn't see that R1 holding fork in their hand. Interviewed S4 stated that was another episode of R2's behavior that R2 tried to go to room #238 and was redirected by S4. The Executive Director and staff interviewed stated that there are always enough staff to always supervise R2 and other residents and that room / residents checks are every 2 hours. Executive Director also mentioned that Police Officer from Pasadena Police Department came to the facility to do a wellness check. The Police Officer gave a case number with no report. Copy of Police case number was provided to LPA. Interviewed R1 stated that R2 entered their room uninvited and they told R2 to leave the room. R1 stated that staff is nice and helpful. Interviewed R3 stated once R2 entered his/her room and when they told R2 to leave, R2 left the room. Interviewed R12 stated that R2 sometimes enter their room when the door is not closed, but it's not bothering them. Interviewed R4, R7, R1 and R14 were unable to answer due to cognitive skills. Interviewed R5, R6, R8, R9, R10, R13, stated that they don't know R2 and no one entered their room uninvited. 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.