complaint·October 21, 2025

The investigation revealed the following: Allegation Staff pushed resident It is being reported that staff pushed a resident. On 10/21/25, LPA Felisa Shirley reviewed the incident reports for R-1 and observed that, S-3 and S-4 observed R-1 being upset and screaming at S-1 per incident report dated 10/5/25. Per review of Exodus Recovery, Client AfterCare Plan, R-1 was transferred by the police department to a recovery program following the incident involving the attack of a staff member. Per interviews conducted on 10/21/25, S-3 and S-4 observed R-1’s elbow approaching S-1’s neck/throat. Per S-4’s written statement, she observed R-1 kick the Med Room door shut. LPA interviewed staff 1 – staff 6 (S-1 – S-6). Of those interviewed 4 out of 6 denied the allegation, 2 did not know. LPA interviewed resident 1 – resident 10 (R1 – R10). Of those who interviewed 9 denied the allegation, 1 confirmed the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff pushed resident,” therefore, the allegation is unsubstantiated. Allegation Staff refused to give resident medication It is being reported that staff refused to give R-1 their medication. Per interview with S-3 on 10/21/25, R-1 called the front desk requesting their medication and was told to come down to the Med Room. S-1 stated that he observed R-1 visibly shaking when the resident entered the Med Room from the wrong entrance for residents and S-1 sat R-1 down to assist and assess the resident to report to the doctor when suddenly R-1 began yelling and slammed the door shut. LPA interviewed staff 1 – staff 6 (S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 10 (R1 – R10). Of those who interviewed 8 denied the allegation, 2 confirmed the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff refused to give resident medication,” therefore, the allegation is unsubstantiated. Con'd on 9099-C Allegation Staff did not treat resident with respect It is being reported that staff did not treat a resident with respect. Per review of Unusual incident reports dated 10/14/25, R-1 was transferred to Los Angeles Downtown Medical Center, (LADMC) on an ordered 51/50 hold secondary to aggressive and violent behavior towards S-1 on 10/5/25 and is currently still in the medical center. LPA interviewed staff 1 – staff 6 (S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 10 (R1 – R10). Of those who interviewed 8 denied the allegation, 1 confirmed the allegation and 1 was not sure. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not treat resident with respect,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Wellness Director, Brooke LaMotte.