Complaint·June 5, 2025

Regarding the allegation "Facility staff did not seek timely medical care for resident,” It is being alleged that staff did not immediately call 911 after verifying that a resident was unresponsive. Records review revealed the following: Facility Daily Time Sheet revealed staff S2 and S3 were working at facility on 11/11/2024. The Emergency Medical Services report indicates that on 11/11/2024 at around 10:52am the paramedics arrived at the facility, observed that R1’s pulse was low and transported R1 to Torrance Memorial Hospital. Interviews indicate the following: S2 indicated that on 11/11/2024 around 9:00am, S2 observed R1 to be unresponsive. S2 and W2 attempted to wake R1 and W2 told S2 not to call 911 which S2 complied. S2 indicated that W1 arrived at 10:30am, attempted to wake R1, and then W1 called 911. S2 acknowledged S2 should have called 911 regardless of W2. W1 indicated finding out that R1 has been unresponsive for 90 minutes and W1 decided to call 911. On 02/13/25, CDSS Staff interview with W2 indicated S2 wanted to call 911 but W2 told S2 not to call. Regarding the allegation “Facility staff did not seek timely medical care for resident,” based on record reviews and interviews, the preponderance of evidence has been met therefore the allegation is Substantiated. Deficiencies were issued. An exit interview was conducted and plans of correction developed. A copy of this report, and appeals rights was reviewed and left with the Co-Administrator Rodolfo "Nino" Lozada.