complaint·May 29, 2025

The investigation revealed the following: Regarding the allegation “Facility staff caused bruising to resident in care”, it is being alleged that a resident was bruised by staff while being redirected back to their room during an elopement. Record reviews indicate the following: Surveillance records (dated: 11/08/24) indicates that R1 was brought back to their room through a two-person carry by S1 and S2. S1 was carrying R1 by the legs and S2 was carrying R1 by the armpits, as the staff transported R1 back to their room. LPA observed S1 grasp R1's left elbow while S1 attempts to close R1's door, before redirecting R1, by the armpits, further into their room. Hospital Medical record (dated: 11/11/24) indicates that R1 was admitted at Torrance Memorial Medical Center (TMMC) on 11/11/24 at 3:25PM by ambulance, with bruising on R1’s upper extremities. Hospital Medical record included photography of R1’s upper extremities and armpits, which depicted three (3) purple marks on R1’s left forearm, three (3) purple marks on R1’s right forearm and bruising in R1’s armpits. Interviews revealed that S3 has agreed that Emergency Medical Services (911) should have been contacted after R1’s first elopement incident on 11/08/24. Based on CCLD’s record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be substantiated. California Code of Regulations, Title twenty-two (22), Division six (6), is being cited. Please see the attached LIC 9099D.