Complaint·November 8, 2025

This complaint was referred to the California Department of Social Services Investigation Bureau for investigation and was assigned to Investigator Christine Ferris. As part of the investigation, Investigator Ferris subpoenaed medical progress notes from Besht Wellness Center (dated 06/13/25), Hollywood Presbyterian Medical Records (dated 07/08/25), Home Health Care Medical Records (dated 01/24/25), Behst Wellness Center Medical Records (dated 06/01/25) Besht Wellness Center (dated 07/01/25) Besht Wellness Progress Notes (dated 05/14/25), ALSO Home Health Care, Inc (dated 01/09/25), Professional Care Home Health, Inc (dated 05/10/25) and Besht Wellness Center Progress Notes (dated 06/15/25). Furthermore, the investigator conducted interviews with Staff #1- #4(S1-S4), Witness #1-W#2 (W1-W2), and Resident #1-#2 (R1-R2). INVESTIGATION REVEALED THE FOLLOWING: ALLEGATION #1: Staff did not seek timely medical attention for resident leading to hospitalization. ALLEGATION #2: Staff refused to call 911 for resident. It has been alleged that Resident #1 (R1) did not receive timely medical attention, which ultimately resulted in hospitalization. Additionally, staff allegedly refused to call 911 when needed. Between June 1, 2025, and June 3, 2025, it was noted that (R1) was in pain and was being treated with pain patches and pain pills. During this time, the facility was contacted several times, but no one was available to respond to the calls. On June 14, 2025, a request was made for (R1) to receive hospital treatment for the right arm, but staff again refused to call 911. The facility maintains that it is not responsible for transporting the resident to the hospital, even with a doctor's correspondence for medical treatment in place. Staff indicated they needed a physician's referral before contacting 911 for hospitalization, and it was clear they were unwilling to call for emergency assistance. On July 09, 2025, at 11:30 AM, the Department interviewed Resident #1 (R1). (R1) reported to have been living at Hayworth Terrace for about six months (date of placement 12/18/24). (R1) expressed (R1) fell out of bed and informed staff about the fall. (R1) advised staff (R1) was in pain “every day”, and the staff gave (R1) “pain pill”, and place “pain patch” on (R1’s) arm. (R1) added that “No one thought I was hurt”. (Evaluation Report continue LIC 9099-C) On July 09, 2025, and August 11, 2025, between 11:30 AM and 02:00PM, staff members interviewed identified as Staff #1 through Staff #4 (S1-S4) all denied both allegations. (S1-S4) stated they were unaware of any fall involving (R1) and that (R1) never notified them about it. However, (3) out of the (4) staff members were aware or made aware of (R1) being provided with pain pills and pain patches for (R1’s) shoulder pain for several days less or a week. (S1-S4) claimed that (R1’s) pain to the back and right shoulder was due to being “elderly” and had carried a “heavy bag” so complaining was not unusual. (S1-S3) claimed to have no documentation of over-the-counter medications or incidents of falls for (R1). Regarding the procedure for contacting emergency services, (S1) stated that Besht Wellness Center has instructed its staff to call 911 and arrange for Non-Emergency Medical Transportation (NEMT) when necessary. According to (S2), policy dictates that if a resident falls and sustains an injury, 911 should be called or the resident should be taken to see a doctor. On July 07, 2025, at 11:00 AM, the Department interviewed Witness #1 (W1). According to (W1), on May 22, 2025, (W1) was informed about (R1's) bed fall, and the facility cannot contact 911 without a doctor's approval. On July 31, 2025, at 03:00 PM, the Department interviewed Witness #2 (W2). (W2) reported that an X-ray order was sent to Besht Wellness Center on May 2, 2025, by (S4). (R1) had been experiencing moderate pain for seven days. The X-rays were performed on May 8, 2025. (W2) confirmed that (R1's) shoulder issue was classified as “chronic” because treatment did not start until May 14, 2025, despite the pain being reported on May 2, 2025. This delay contributed to the chronic classification. On July 30, 2025, and September 17, 2025, between 01:00 PM and 04:00 PM resident members interviewed identified as Resident #2 to Resident #5 (R2-R5). Four (4) of the (4) claimed they were unable to support the staff's refusal-to-contact-911 allegation. (R2-R5) were unaware of any harm and denied knowing about the staff's refusal to provide timely medical assistance with 911. The Department reviewed medical progress notes from Besht Wellness Center (dated 06/13/25), which indicated that attempts to reach the facility regarding (R1’s) fracture were unsuccessful. “Attempted to contact the facility multiple times using all phone numbers on file; no answer and disconnected.” Transfer orders were sent to the facility by fax on May 13, 2025, due to a lack of response. (Evaluation Report continues LIC 9099-C) Besht Wellness Center sent an email to the facility stating (R1’s) X-Ray shows a fracture-dislocation of the proximal humerus and advised (R1) to be transported to the emergency department for treatment via (NEMT). Further review of the Hollywood Presbyterian Medical Center medical records (dated 07/08/25) reported an inability to reach the facility, as noted in the documents, “Multiple attempts were made to reach staff at the assisted living facility with no success.” Medical records revealed (R1) notable for an obvious deformity,” and “it is possible that since the shoulder might have been out for up to a week, reduction is no longer possible.” The Department reviewed the California Department of Social Services Provider Information Notice (PIN) 25-06-ASC, dated June 24, 2025. The notice states that it is best practice for the licensee to immediately call 9-1-1 if a resident is experiencing serious injuries, such as “obvious broken bones”, or if they have “falls with complaint of pain or loss of range of motion.” Based on the gathered information, the facility showed no urgency in following up on June 6, 2025, X-ray results, despite staff knowing that (R1) was in "severe pain," according to (S4) and medical records. Hollywood Presbyterian Medical Center indicated (R1's) fracture required surgery, likely due to the delayed medical attention. The staff noted that (R1) had significant pain for a week, relying on over-the-counter medications for relief. However, there was a lack of communication about arranging Non-Emergency Medical Transportation (NEMT) to meet (R1's) needs. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citation issued (ref. LIC 9099D). *Immediate Civil Penalty issued* An exit interview was conducted with , and copies of the reports were provided. This complaint was referred to the California Department of Social Services Investigation Bureau for investigation and was assigned to Investigator Christine Ferris. As part of the investigation, Investigator Ferris subpoenaed medical progress notes from Besht Wellness Center (dated 06/13/25), Hollywood Presbyterian Medical Records (dated 07/08/25), Home Health Care Medical Records (dated 01/24/25), Behst Wellness Center Medical Records (dated 06/01/25) Besht Wellness Center (dated 07/01/25) Besht Wellness Progress Notes (dated 05/14/25), ALSO Home Health Care, Inc (dated 01/09/25), Professional Care Home Health, Inc (dated 05/10/25) and Besht Wellness Center Progress Notes (dated 06/15/25). Furthermore, the investigator conducted interviews with Staff #1- #4(S1-S4), Witness #1-W#2 (W1-W2), and Resident #1-#2 (R1-R2). INVESTIGATION REVEALED THE FOLLOWING: ALLEGATION #3: The resident suffered a dislocated shoulder due to staff negligence. It is alleged that Resident #1 (R1) suffered a dislocated shoulder due to staff negligence. On May 22, 2025, (R1) was observed with their right arm hanging limp and dragging, and (R1) complained of pain. When this was reported to the facility staff who stated that the hanging arm was due to old age and was not a concern. Additionally, it was noted that facility management was unable to provide clarification on the matter during multiple inquiries. No further details about this incident were provided. On July 09, 2025, at 11:30 AM, the Department interviewed Resident #1 (R1). (R1) reported to have been living at Hayworth Terrace for about six months (date of placement 12/18/24). (R1) expressed (R1) fell out of bed and injured the shoulder. (R1) did not call for assistance prior to or after the fall and is able to lift self from the floor, which (R1) did after the fall. The facility had no documentation of (R1) notifying them of a fall and denied any know of a fall. On July 09, 2025, and August 11, 2025, between 11:30 AM and 02:00PM, staff members interviewed identified as Staff #1 through Staff #4 (S1-S4) who are unable to support this claim. (S1-S4) stated they were unaware of any fall involving (R1) and that (R1) never notified them about it. Additionally, there was no documentation from the facility indicating any notification from (R1) regarding the fall. (Evaluation Report continues LIC 9099-C) On July 07, 2025, at 11:00 AM, the Department interviewed witness member identified as Witness #1 (W1). (W1) was not aware of (R1's) fall or fractured shoulder until (R1) disclosed the injury on May 22, 2025. During this conversation, (R1) mentioned that (R1) had fallen out of bed and was experiencing pain in the right shoulder. According to (W1), no one at the facility had notified (W1) about the fall. The Department reviewed medical progress notes from Besht Wellness Center (dated 06/13/25) where (R1) denied any recent falls but per Hollywood Presbyterian Medical Records (dated 07/08/25) (R1) reported (R1) fell out of bed but did not not know when it occurred. Further review of the Physicians Report LIC 602A (dated12/23/24), and Home Health Care Medical Records (dated 01/24/25). Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated . An exit interview was conducted with the Licensed Vocational Nurse, Hee Kyung Park, and copies of the reports were provided.