Incident investigation·June 15, 2021

Licensing Program Analysts (LPAs) Sandra Urena and Ashley Morgan conducted a case management visit today to issue the final report regarding an investigation. The LPAs met with Administrator Cyntia Drachenberg and explained the reason for the visit. On 09/28/2020, LPA Eva Miller reviewed a voicemail message that was received on Friday, 9/25/20 at 9:14 a.m. from Administrator Cyntia Drachenberg, as LPA Miller was off-duty on 9/25/2020. Per the voicemail message, on 9/24/2020 at approximately 4:15pm, staff #2 (S2) stabbed staff #1 (S1) in the back with a knife several times, while in the facility kitchen. 9-1-1 was called, and the paramedics (EMS) and Law Enforcement arrived. S1 was transported to the hospital with 5 to 6 stab wounds in the back. S1 expired shortly after arriving at the hospital for severe injuries to the heart and lungs. S2 was arrested by the Los Angeles Police Department (LAPD), and taken into custody. On 9/28/2020, LPA Miller conducted a phone interview with the Administrator to obtain detailed information regarding the incident and to determine if there were any health and safety concerns. The LPA also requested that an incident report be submitted, which was received the same day. Furthermore, on 9/28/2020, the Department referred this case to the Investigations Branch (IB) for investigation and on 09/29/2020, (IB) Investigator, Lorraine Patterson , Badge #114, was assigned to investigate the incident . On 9/30/2020 at approximately 3:05 p.m., IB Investigator Patterson obtained and reviewed the criminal history for S2. In addition, on 9/30/2020, Investigator Patterson also requested a copy of LAPD’s report. On 10/05/2020 at 2:15 p.m., LPA Miller initiated a follow-up health and safety check and discussion with the Administrator. The Administrator who confirmed that no residents were involved and that there was an active Police Investigation. Per the Administrator, S1 had never interacted with residents in care the entire 10 years of S1’s employment at the facility, as S1 was a cook. S1 spoke little English and basically just stayed in the kitchen. S2 had only been working at the facility for about 3 weeks as a dishwasher. Though the residents and/or their responsible persons had been properly notified of the incident, there have been no reports of any issues with or by the residents. All residents were safe. Counselors were brought in and were available to staff and residents all weekend. On 11/5/2020, the LAPD report was received by Investigator Patterson. On 11/5/2020 at approximately 8:51 a.m., Investigator Patterson interviewed the lead detective assigned to this case from the LAPD Valley Bureau, Homicide Division. On 11/6/2020 at 11:40 a.m., Investigator Patterson interviewed the administrator, Cyntia Drachenberg. In addition, as part of the investigation, the investigator reviewed the LAPD Investigative Report, the incident report, along with the facility file. The interview with the Detective revealed that S2 thought that S1 was talking about S2; further, S2 admitted that S2 stabbed S1 at the facility with a knife, which resulted in S1 dying. The Detective reported that the homicide investigation is complete. S2 is in custody, and LA District Attorney’s Office has filed murder charges against S2. Based on the interviews with the Administrator and the LAPD detective, the investigatory leads, records, and information obtained and reviewed, Investigator Patterson found that there is enough preponderance of evidence to prove Conduct Inimical on behalf of S2; however, there was no evidence to suggest that the facility staff and/or facility administration were involved with, had knowledge of or could have prevented S2’s behavior, given the circumstances. No deficiencies cited. Exit interview conducted. Signatures obtained. A copy of the report was issued.