complaint·September 5, 2024

The investigation revealed the following: On 06/24/2023, in the morning, upon arrival at the facility, S2 found two residents R1 and R2 inside the restroom on the floor, unresponsive, and dead upon arrival. S2 immediately called 911. According to the Los Angeles Sheriff’s Department (LASD) S2 observed that “bags were placed over the R1’s and R2’s face by S1. S1 placed bags over the two residents (R1 and R2) heads, and possibly killed them.” Per LASD report before S2 contacting 911, at approximately 7:52 pm. S1 contacted 911 and self-reported the incident. Per S1 911 call, S1 admitted to the dispatcher that S1 just killed two residents / elderly people. On 6/25/23, Regional Manager Araceli Ramirez and LPA Kimberly Ramirez conducted a health and safety check at the facility and gathered documents pertaining to R1, R2, S1, and S2. During the visit on 06/25/23, it was discovered that S1 was arrested for the murder of two residents of the facility. On 06/30/23, Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management Visit and an immediate civil penalty of $500 were issued for allowing S1 to work in the facility prior to obtaining a background clearance. Investigations Branch (IB) investigator conducted the investigation. On 08/08/24 Investigator interviewed the licensee/administrator and S2. Investigator also obtained the L.A. County Sherriff’s report and 911 calls made to the Walnut Sheriff’s Station. On 8/24/23, Investigator interviewed S1 while in custody. S1 admitted to the murder of R1 and R2 but did not want to go into further details of how the incident occurred. The investigation revealed that S1 started working and residing at the facility on 06/01/23. However, S1’s background clearance did not clear until 06/16/23. Therefore, the licensee allowed S1 to begin working and residing at the facility prior to obtaining a criminal record clearance. On 10/10/23, Licensing Program Analyst (LPA) Cynthia Chan conducted Case Management visit and another immediate civil penalty of $500 was issued due to neglect. On 06/05/24 CCLD received a complaint alleging neglect. Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 06/07/2024 regarding the above allegations. LPA Ramirez conducted a Health & Safety Check tour with Administrator and obtained staff and residents’ roster. Continue 9099C On 09/04/24, Enhanced Civil Penalty (ECP) was issued by Licensing Program Analyst (LPA) Cynthia Chan due to a civil penalty per Health and Safety Code 1569.49(e) for a violation that the Department determines resulted in the death of two residents in the amount of $30,000 ($15,000 for each death of a resident). However, since an immediate civil penalty of $500 was previously issued on October 10, 2023, the amount of the civil penalty will be $29,500. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED, however deficiencies previously issued during case management and office visits. Exit interview was conducted and the copy of this report along with appeal rights were provided to Kim Eunice, Administrator.