complaint·May 4, 2023

Department of Social Services -Community Care Licensing Division (DSS/CCLD) Investigator Laura Garcia conducted the following: interviewed R-1’s authorized representative, obtained Coroner’s Report, obtained a copy of Glendale Police Department incident report, obtained medical records, interviewed Facility Executive Director, Interview Staff #1 (S-1) through Staff #6 (S-6) and interviewed R-1’s hospice agency. Allegation : Resident sustained serious fall resulting in death. Per Investigator Garcia’s interviews and documentation obtained “there was insufficient evidence to determine if there was neglect/lack of supervision on behalf of facility members which lead to the death” of R-1. Per Investigator Garcia’s investigation, the cause of death noted on R-1’s death certificate was not due to a fall. Per Investigator Garcia, R-1 passed away on 05/04/2021 while residing at another facility. Per documentation reviewed, R-1 was discharged/moved out from this facility on 03/24/2021. Interviews conducted and documentation obtained do not corroborate this allegation. Allegation: Resident sustained unexplained bruising while in care. Per Investigator Garcia’s interviews and documentation obtained, (S-6) “denied ever hurting” R-1 or “striking” R-1. Glendale Police Department conducted interviews and “was unable to determine if a crime had occurred”. Interviews revealed that R-1 was aggressive and was known to display self injurious behaviors. Hospice documented that R-1 also bumped self with furniture which may have contributed to unexplained bruising. Interviews revealed that R-1’s authorized representative was aware of R-1’s behaviors. Staff interviews revealed that staff had not witnessed any staff physically abusing R-1. Staff interviews revealed that they did not receive any concerns/complaints in regards to R-1. Interviews conducted and documentation obtained do not corroborate this allegation. Allegation: Resident lost significant amount of weight while in care. Hospice documentation indicate that R-1 preferred to sleep and skip meals due to the “grogginess” of the medications which was communicated to R-1’s authorized representative. Per S-4, staff document residents’ weight on a monthly basis. LPA obtained weight records for R-1 from December 2020 (Admission) through March 2021 (Discharge). Upon discharge/move out date (03/24/21), R-1 had a weight difference of (4) pounds. Per interviews conducted, staff and hospice agency were in constant contact with R-1’s authorized representative about R-1’s health and needs. Interviews conducted and documentation obtained do not corroborate this allegation. Refer to LIC 9099C for the continuation of this report. Allegation : Resident's care needs were not met while in care. It is alleged that this facility staff was not providing R-1 with care needs while in care. Based on reviewed documents and interviews conducted, the facility staff informed R-1’s authorized representative and hospice agency of R-1’s change in condition. The facility staff also submitted special incident reports for R-1 to Community Care Licensing. Interviews conducted and documentation obtained do not corroborate this allegation. Allegation: Facility denied access to Ombudsman. It is alleged that the facility denied access to Ombudsman. LPA attempted to have contact with Ombudsman and was unable to reach a representative. Per S-4, staff do not deny access to Ombudsman. Per S-4, Ombudsman staff come in and request a copy of the resident roster (proper identification is reviewed/confirmed) prior to releasing a copy of the resident roster. Per S-4 once this step is completed, Ombudsman visits the residents in their room privately. Per S-4, S-4 has not received any requests for resident records nor recalls any Ombudsman representative visiting R-1. Interview does not corroborate this allegation. Based on record review and interviews conducted the findings indicate, although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are UNSUBSTANTIATED. An exit interview conducted, appeal rights and a copy of this report was provided to Brenda Chacon.