complaint·March 20, 2023

Allegation: “Lack of supervision resulting in resident causing injury to another resident in care.” It is alleged on or about 06/10/2021, R5 received an injury from R6 due to lack of supervision. Four (4) out of the four (4) staff interviewed confirm R5 did receive an injury from R6. Four (4) out of the four (4) residents interviewed deny this allegation. LPA reviewed Unusual Incident/Injury Report (LIC 624) dated 06/10/2021 which documented the alleged burn to R5’s hair by R6. R5 refused medical treatment. LPA was able to verify local law enforcement was called on 06/10/2021 and R6 did not return to facility after 06/10/2021. R5 has since passed away and R6 was transferred to another facility to better meet needs and services. LPA could not locate R6 and was unable to interview. LPA Ramirez was able to obtain DA Case Number 41226218 and verified through the Los Angeles County District Attorney's Office that charges against R6 were not upheld. Allegation: “Resident has access to a hazardous item.” It is alleged on or about 06/10/2021, R6 had access to a hazardous item that caused injury to R5. Four (4) out of four (4) staff deny this allegation however, staff did acknowledge that residents in care do smoke cigarettes and require a lighter to light their cigarettes. S2 denied facility staff had prior knowledge that R6 would use or could use a lighter in a hazardous way on or around 06/10/2021. LPA could not locate any pertinent documentation that suggested R6 could not safely possess lighter while in care. Allegation: “Staff did not safeguard resident's personal belongings.” It is alleged on or about 06/10/2021, R6 stole items from R5’s room. Four (4) out of the four (4) staff interviewed denied this allegation. Four (4) out of the four (4) residents interviewed denied this allegation. LPA could not locate any pertinent documentation to support this allegation. Allegation: “Resident does not have access to the bathroom.” It is alleged on or about 06/10/2021, R5 was unable to access restroom due to R6 locking door and prohibiting access to R5. Two (2) out of the four (4) staff interviewed denied this allegation. S1 acknowledged R6 and R5 had a “Jack and Jill Bathroom” and R6 did lock the bathroom door so R5 would not walk in while R6 was occupying the restroom. According to S4, staff reminded R6 to unlock connecting bathroom door so R5 may gain access. Four (4) out of the four (4) residents interviewed deny this allegation. According to S1, this incident only occurred once and was addressed immediately. LPA could not find any other supporting evidence to suggest this allegation continued or occurred after R6 was addressed. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.