complaint·April 9, 2026

Interviews with Witness #1 (W1) and Witness #2 (W2) revealed concerns that R1 was manipulated by the facility into marrying S1 for immigration or green card purposes. Interviews with R1 revealed that R1 did not feel pressured into marrying S1, and R1 denied any coercion from S1 or facility staff. Interviews with S1 and R1 revealed that they intended to go to the immigration office to obtain documents for S1, but no such visit took place due to issues in obtaining the required perquisite documentation. LPA reviewed R1’s medical documentation and facility file. R1 was determined by their physician to not have cognitive deficit, was able to make their own decisions, and was able to manage their own finances. Additionally, LPA observed R1 to be self-responsible and did not have a Power of Attorney (POA). On 03/18/2026, LPA interviewed S1 and R1. LPA was informed that as of 02/17/2026, S1 and R1 were legally separated. Based on interviews and record review there is sufficient evidence to support the allegation of “Staff engaged in an inappropriate relationship with resident.” Therefore, the allegation is deemed Substantiated at this time. The allegation of “Staff did not seek timely medical attention for resident” alleges that the facility did not seek timely medical attention for R1 following a medical emergency which occurred at the facility. Interviews with S1 revealed that on 05/14/2025, R1 suffered a medical emergency at the facility and required hospitalization. S1 stated that symptoms, including diarrhea, were first noticed the day prior (05/13/2025) and were monitored by S1. S1 stated that on 05/14/2025, they observed blood in R1’s stool. S1 reported observing the blood for approximately two (2) to three (3) hours before calling the Administrator and later emergency services to transport R1 to the hospital. LPA interviewed the Administrator who stated that R1 appeared fine on the morning of 05/14/2025, but around 12:00 PM R1’s blood pressure was observed by S1 to be rapidly dropping. Administrator stated that they received a follow-up call from S1 at approximately 05:00 PM informing them that R1 was not doing well. Administrator stated that an ambulance was called for R1 at approximately 06:00 PM and R1 was transported to the hospital for treatment. LPA reviewed the hospital paperwork from R1’s 05/14/2025 hospitalization. LPA observed that R1 was admitted to the hospital in critical condition with severe hyperkalemia (high potassium levels in blood) and later suffered cardiac arrest. Based on interviews, LPA observed a delay in seeking timely medical attention for R1 of more than twenty-four (24) hours from the initial onset of symptoms and six (6) hours of the presentation of severe symptoms. Based on interviews and record review there is sufficient evidence to support the allegation of “Staff did not seek timely medical attention for resident.” Therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted and copy of the report was issued and appeal rights provided.