complaint·November 5, 2025

On 10/01/25, LPA retrieved a copy of R1’s Morphine Record (08/04/25), Physician’s Reports (R2 – R6), Updated Training Record (S1) and interviewed Witnesses #1 - #2. On 10/13/25, LPA received R1’s records from Home Care Visit in Providence Hospice LA County. On 10/16/25, LPA interviewed Witness #11. On 10/17/25, LPA interviewed Witness #5, #7, #9 and #10. On 10/30/25, LPA received R1’s death certificate. On 11/03/25, LPA interviewed Staff #9 - #10. Note: LPA left a message/voicemail to interview Witness #6, #8 (09/17/25, 09/29/25, 10/17/25). Regarding the allegation, “Staff did not inform responsible party of resident's change of condition,” it is being alleged that R1 collapsed on 07/29/25 and the responsible parties were not notified. Record review of Home Care Visit in Providence Hospice LA County (Encounter Notes) revealed on 07/29/25, R1 lost consciousness after dinner, per B&C caregiver. R1 was taken to his bed, however, R1’s health continued to decline and R1 became unresponsive and bedbound since 08/01/25. Record review of staff schedule (07/29/25) revealed that S7 worked from 3 PM - 12 AM, S3 worked from 6 AM - 6 PM, S8 worked from 11 AM - 8 PM, S1 worked from 7 AM - 4 PM, and S6 worked from 12 AM - 9 AM. Interview with Hospice Nurse (Witness 11) indicated W11 was unable to recall the name of the B&C caregiver but indicated that the staff was a woman (S1, S3, S6 - S7). Five out of five staff interviews (S1, S3 and S6-S8) indicated R1 did not collapse nor fall. Interview with the Administrator indicated that there were no reports of R1 collapsing. S7 indicated that R1 did not collapse but during dinner, S7 noticed R1 was getting tired so R1 was assisted to R1’s room. Four out of six responsible party/witness interviews (W4 – W7, W9 - W10) indicated they are notified of incidents and changes of resident’s condition. Regarding the allegation, “Staff did not inform responsible party of resident's change of condition,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. An exit interview was conducted over the phone with Area Manager Irene Formentera and a copy of this report was provide to Staff.