Incident investigation·February 20, 2025

Licensing Program Analyst (LPA) Nune Margaryan conducted Case Management - Incident visit and met with Administrator and DOHS (Director of Health Services). LPA explained the purpose of today's visit and conducted a health & safety check of residents in care. Unusual Incident report involving the former Resident 1 (R1) was submitted by the facility on 02/10/25. Incident report has indicating that R1's private caregiver was force feeding R1. R1 was passed away on 02/09/25 due to diagnosis End of Stage of Alzerheimers Disease. During today's visit LPA interviewed DOHS, Kaiser Hospice Social Worker (SW), Family Member 1(FM1). Family Member 2 (FM2) was interviewed on 02/19/25. LPA reviewed R1's file and obtained copies of the following documents: Admission Record Face Sheet Physician's Report Hospice order for R1 about NPO dated 07/09/25. LAPD Officers information / notes. Record of Death At the time of visit LPA did not observe nor identify signs of neglect, abuse or other immediate health and safety threats. An exit interview was conducted, and a copy of the report was provided to DOHS Milca Osorio.