complaint·August 9, 2024

Continued LIC9099-C page 2 No evidence of neglect or abuse was observed during these visits. We reviewed the resident files, including the physician's report, medical records, admission agreement, identification and emergency information, medication records, medication administration records (MARs), medication logs, medical assessments, consent forms, hospital records, incident reports, appraisal & needs service plan. LPA Bunker requested copies of supporting documents. Allegation: Resident sustained an unexplained injury while in care. Interviews with staff members 1-3 (S1-S3) indicated that the resident did not sustain an unexplained injury while in care. S1-S3 stated that the resident does not receive one-on-one care. S1-S3 reported that on August 8, 2023, at approximately 6:30 A.M., after completing the resident's morning grooming routine, caregiver Karina Portillo (S2) assisted the resident in being seated on the bed. While retrieving the resident's clothing from the closet, S2 suddenly heard a loud noise coming from the bathroom. Upon further investigation, S2 discovered that the resident had gotten up independently and proceeded to the bathroom. R1 had accidentally fallen and was found attempting to get up from the bathroom floor. S2 immediately assisted the resident back to bed, where she noticed a cut on the resident’s left cheek, which was bleeding. S2 promptly called for assistance, and Med Tech Edwin Villanueva responded immediately. The Med Tech called 911 without delay, and the resident was transported to Cedar Sinai-Marina Del Rey Hospital. The resident’s responsible party, family, and physician were notified. S1-S3 stated that S2 could not have prevented R1 from falling. S1-S3 stated that staff are adhering to the resident's discharge instructions, monitoring the resident's condition closely, and keeping the family informed of the resident's progress. S1-S3 stated that the resident was not hit, and no staff member witnessed any such incident. Interviews with Residents 2-9 (R2-R9) revealed that they did not witness the resident falling or any instance of a resident being hit. R2-R9 expressed that they feel safe, are happy with the care and supervision provided, and believe that the staff are doing an excellent job. S1-S4 emphasized that this is a 24-hour care facility, operating 7 days a week, 365 days a year, ensuring the safety of residents at all times. See continued LIC9099-C page 3 Continued LIC9099-C page 3 Investigation revealed the following: Staff members 1-3 (S1-S3) stated that the resident experienced an accidental fall on the morning of August 8, 2023. Emergency 911 services were immediately contacted, and the resident was transported to Cedars-Sinai Marina Del Rey Hospital. According to S1-S3, the fall was unavoidable, and no staff members or residents witnessed the incident or observed any physical altercation involving the resident at the facility. The Inglewood Police Department responded to a call from Westchester Villa and concluded that no crime had occurred, resulting in no police report being filed. Medical records from the resident's physician and Cedars-Sinai Marina Del Rey Hospital confirmed a diagnosis of dementia, indicating that the resident is unable to manage their treatment, medication, or equipment. The resident also suffers from significant cognitive impairments, including difficulties with thinking, remembering, reasoning, judgment, and decision-making, which interfere with their ability to perform daily living activities or engage in social or occupational activities. Staff members S1-S4 emphasized that Westchester Villa operates on a 24/7 basis, ensuring that residents are never left unattended. Residents R2-R9 confirmed that staff members are consistently available to assist and expressed satisfaction with their living conditions at the facility. S1-S4 and R1-R9 stated that the accommodations provided are comfortable and that the staff is dedicated to ensuring the safety and well-being of all residents. S1-S3 and R2-R9 denied any occurrence of a fight. Investigator Juan Lozano of the Investigations Branch (IB) completed his investigation Care Report and determined that the findings were unsubstantiated. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099, and LIC9099-C, was provided to the Administrator Tawny Gant . There were no deficiencies cited. An exit interview was conducted.