Follow-up on corrections·July 24, 2024

At approximately 10:15 a.m. on 07/24/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with Co-Administrator Ed Galang and Director Chris Salvador and disclosed the reason for the visit. Today’s case management visit is a subsequent visit to deliver findings from the 09/29/23 case management visit conducted by LPA Reed and Licensing Program Manager (LPM) Naira Margaryan. On 09/26/23 the facility submitted an incident report in which Resident #1 (R1) and Resident #2 (R2) required medical assistance due to injuries on the morning of 09/20/2023. R1 experienced rib pain and a head laceration, and R2 was found bleeding and unresponsive. The facility later submitted R2's death report. LPA and LPM conducted an initial visit on 09/29/23 and interviewed two (02) staff and three (03) residents between 9:00 a.m. and 11:00 a.m., reviewed records at approximately 10:15 a.m. and 11:30 a.m. including but not limited to service plans, medical assessments, incident reports, and an observation log, and toured the facility at approximately 10:40 a.m. The case was referred to the Investigations Branch on 09/29/23. Between 10/17/23 and 03/21/24, Investigator Juan Lozano reviewed the hospital medical records of R1 and R2 and reviewed an LAFD report and an LAPD report from the 09/20/23 incident. A County Clerk death report for R2 was obtained and reviewed on 04/12/24. The case was referred to Investigator Phillipe Miles on 04/17/24. Investigator Miles interviewed additional staff between 04/17/24 and 06/05/24. Record review of incident reports, service plans, and medical assessments indicated the facility was aware of R1’s and R2’s substance abuse of alcohol. Service plans indicated that facility staff would encourage both residents not to drink. Incident reports indicated the facility attempted to address R1’s substance abuse through therapy, educational physician meetings, and written and verbal warnings. The facility issued an eviction notice to R1 on 06/13/23, but R1 remained at the facility. The incident report from 09/26/23 indicated that R1 and R2 “prior to admission and during stay at [the facility] have had alcohol substance abuse issues” and that Staff #1 (S1) performed a room check on R1 and R2 “around 4 – 5 AM where everything was fine”. Interview with Staff #2 (S2) at 2:30 p.m. on 05/14/24 revealed R1 and R2 were friends, were independent, required minimal supervision, and were known to have “on and off” histories of alcohol abuse. S2 further stated that on the morning of 09/20/23, R1 walked to the medication room where S2 observed blood on R1’s shirt and a laceration on their head. After R1 was transported to the hospital, S2 searched for R2 and discovered R2 in their room with blood around them and breathing heavily. That morning, S2 had called 9-1-1 for both R1 and R2. Interview with Staff #3 (S3) at approximately 11:45 a.m. on 04/17/24 revealed R1 was verbally and physically abusive and had previously kicked S3. S3 never reported the incident to police. However, S3 did report the occasions which the room of R1 and R2 was checked, smelled of alcohol, and bottles of alcohol were discovered. Interview with Staff #4 (S4) at approximately 10:30 a.m. on 06/05/24 revealed R1 and R2 were friends who sometimes fought, drank, and smoked in the facility. S4 also stated that the nighttime staff did not check on R1 or R2 prior to the incident on 09/20/23. Review of an LAPD police report indicated that R2 was admitted to the hospital with a Blood Alcohol Content of .135 and had suffered a subdural hemorrhage. Officer Galvez interviewed R1 at the hospital at approximately 2:00 p.m. on 09/26/23. R1 told Galvez they and R2 had each drank two (02) bottles of vodka prior to the incident, though R1 denied any altercation between the two residents or any knowledge of how their injuries came about. R2 passed away on 09/23/23 after their family chose not to elect for further surgical procedures. R2’s death certificate showed “Sequelae of blunt head trauma” as their cause of death. The facility’s daily monitoring log indicated that on 09/20/23, R1 was last checked on at 6:00 a.m. and R2 was check on at 6:00 a.m. and 8:00 a.m. Based on interviews and record review, the facility did not provide sufficient care and supervision to R1 and R2. The facility was aware of R1 and R2 consuming alcohol against the house rules. The facility was also aware of R1’s history of physical and verbal abuse. Therefore, the facility did not adequately protect R2 from serious injury at the facility. A deficiency is cited on the corresponding LIC 809-D page. A $500 immediate civil penalty is assessed today for a violation resulting in injury to R2. The administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Exit interview conducted. Appeal rights discussed. Civil penalties issued. Copy of report provided.