Complaint·January 29, 2026

Additionally, LPA Gonzalez interviewed staff #1-#4 (S1-S4), residents #2-#4 (R2-R4), and attempted to interview witness #1-#2 (W1-W2). LPA Gonzalez was unable to interview R1. Furthermore, LPA Gonzalez and Lucy Ouw toured the facility. On 01/29/26, LPA Gonzalez received the following records: Physician Order Form from TLC Hospice Care, Inc. (dated: 10/25/25). The investigation revealed the following: For the allegation: Staff did not ensure that a resident in care was receiving oxygen. It is being alleged that staff did not ensure that a resident was receiving oxygen or that the resident’s oxygen levels were appropriate. On 11/21/25, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4 staff stated that they followed all physician orders and directives while caring for R1. On 11/21/25, LPA Gonzalez conducted interviews with R2-R4 and was unable to interview R1 as they passed away on 10/28/25. Of those interviewed, 3 out of 3 residents could not corroborate with the allegation. 3 out of 3 residents stated that staff is providing the necessary care and supervision. On 11/21/25, LPA Gonzalez conducted a review of records. Medical records from Cedars-Sinai Hospital dated 10/08/25 indicated that R1 was admitted on 09/30/25 due to swelling in the hands and legs and was discharged on 10/08/25 with diagnoses of Atrial Fibrillation (AFib) and Urinary Tract Infection (UTI). Medical records from Cedars-Sinai Hospital dated 10/25/25 noted that R1 was admitted on 10/19/25 due to low oxygen saturation levels and hypotension. R1 was discharged from the hospital on 10/25/25 under hospice care. A review of the Unusual Incident/Injury Report (UIR) dated 09/30/25 noted that R1 was experiencing severe swelling in the hands and legs and was transported to Cedars-Sinai Hospital for evaluation. The UIR dated 10/08/25 documented that R1 returned to the facility from Cedars-Sinai Hospital on 10/08/25. The UIR dated 10/19/25 indicated that R1 was transported to Cedars-Sinai Hospital due to low oxygen saturation levels observed by staff. The UIR dated 10/25/25 noted that R1 was discharged from Cedars-Sinai Hospital and returned to the facility on 10/25/25 under hospice care with comfort-focused orders. Continued on LIC9099-C The report further noted that R1’s oxygen saturation levels remained low upon discharge and required continuous oxygen to maintain comfort and adequate breathing. Staff ensured oxygen therapy was administered immediately upon arrival per physician and hospice orders. The UIR dated 10/28/25 noted that staff observed R1 with very low oxygen saturation levels despite continuous oxygen therapy, and R1 passed away that afternoon. A review of the Death Report (LIC 624), dated 11/03/25, reported that R1 passed away on 10/28/25 at 5:30 p.m., with contributing factors noted as Alzheimer’s disease and decline. On 01/29/26, LPA Gonzalez received and conducted a review of Physician Order Form from TLC Hospice Care, Inc. (dated: 10/25/25). Record revealed that R1 was prescribed oxygen inhalation as needed for shortness of breath. Based observation, interviews conducted, and records reviewed, there is not enough evidence to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the above allegation is unsubstantiated. For the allegation: Staff did not adequately supervise a resident in care. It is alleged that a resident with Diabetes was able to access a large amount of sweets at the facility without staff awareness. On 11/21/25, LPA Gonzalez conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4 staff said they follow the resident’s restrictive diets. 4 out of 4 staff said residents do not have access to a large amount of candy or sweets. An interview with S1 revealed that staff supervise residents and take precautions to ensure resident safety. S1 stated that ongoing training is provided to facility caregivers and that staff attempt to follow the household menu as closely as possible. S1 reported that residents’ prescribed diets are posted above each resident’s bed and on the resident’s room door. S1 further stated that staff may advise and remind residents regarding their dietary needs; however, staff do not have control over residents’ decisions to order takeout food or purchase their own groceries, which S1 stated is the residents’ right. Continued on LIC9099-C On 11/21/25, LPA Gonzalez conducted interviews with R2-R4 and was unable to interview R1 as they passed away on 10/28/25. Of those interviewed, 3 out of 3 residents could not corroborate with the allegation. 3 out of 3 residents said that facility staff follow their restrictive diet. 3 out of 3 residents stated that staff is providing the necessary care and supervision. On 11/21/25, LPA Gonzalez conducted a tour of the facility. No large quantities of sweets were observed to be accessible to residents. During the tour, LPA observed residents during lunch being served a well-balanced meal consisting of chicken, rice, and vegetables. Based observation, interviews conducted, and records reviewed, there is not enough evidence to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the above allegation is unsubstantiated. No deficiencies were cited during this investigation. An exit interview was conducted, and a copy of the report was provided.