complaint·December 30, 2024

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. Investigation findings were delivered on 07/24/24 and the facility was issued a deficiency for violating HSC §1569.312(e) Basic Service Requirements and an immediate $500 civil penalty. LPA conducted further investigation on 11/05/24 and toured the facility inside and out at 1:30 p.m., interviewed staff and residents between 1:45 p.m. and 3:30 p.m., and conducted a record review at 2:30 p.m. Today, LPA toured the facility at 9:15 a.m. Regarding the allegation "Licensee's lack of supervision led to resident's death" it was alleged the facility did not provide adequate supervision to R1 and R2 which led to R2's death. As noted on the case management report delivered on 07/24/24, 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 and of R1’s history of physical and verbal abuse. The facility did not adequately protect R2 from serious injury at the facility. Therefore, the allegation is deemed SUBSTANTIATED at this time without deficiency since a deficiency was cited during the 07/24/24 case management visit along with a $500 immediate civil penalty for a violation resulting in injury to R2. Exit interview conducted. Appeal rights discussed. Copy of report provided. 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. Investigation findings were delivered on 07/24/24 and the facility was issued a deficiency for violating HSC §1569.312(e) Basic Service Requirements and an immediate $500 civil penalty. LPA conducted futher investigation on 11/05/24 and toured the facility inside and out at 1:30 p.m., interviewed staff and residents between 1:45 p.m. and 3:30 p.m., and conducted a record review at 2:30 p.m. Today, LPA toured the facility at 9:15 a.m. Regarding the allegation "Licensee failed to do a proper assessment on a resident to ensure compatibility with the general population" it was alleged R1 had a history of violence and sexual abuse which the licensee did not properly address. Record review of R1’s Needs and Service Plan update from 11/03/22 revealed they had a history of falls and alcohol use, but there was no indication of physical violence or sexual abuse. Review of R1’s Preplacement Appraisal and Physician’s Report from 08/08/22 indicated R1 did not exhibit aggressive behavior. Interviews with staff and residents on 11/05/24 between 1:45 p.m. and 3:30 p.m. revealed no staff or residents had witnessed or experienced sexual abuse form R1. Interviews with residents revealed no residents experienced or witnessed physical abuse from R1. Interview with S3 revealed they were previously kicked by R1 after R1 had fallen while inebriated. Review of an incident report revealed that on 04/28/23, R1 kicked a door while inebriated which hit Staff #5 (S5). The facility conducted in-service trainings after each incident. Interview with S2 at 2:30 p.m. on 05/14/24 revealed R1 and R2 were “best friends” who required minimal supervision. Interview with Resident #3 (R3) at 10:45 a.m. on 09/29/23 revealed R1 and R2 were like "two peas in a pod". Based on interviews and record reviews, although there were two (02) documented incidents of R1 kicking staff while inebriated, facility and physician assessments of R1 did not indicate incompatibility with the populations of residents. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.