complaint·December 19, 2025

Investigation consisted of the following: On 07/09/2025, interviews were conducted, a tour of the Reminiscence Neighborhood was conducted, records were gathered. Interviews conducted consisted of 7 resident interviews [Resident 2 (R2) to Resident 8 (R8) were interviewed] and 6 staff interviews [Staff 1 (S1) to Staff 6 (S6) were interviewed]. Facility records were gathered which consisted of Resident Roster dated 07/01/2025; Personnel Report; Abuse, Neglect & Exploitation – Prevention, Reporting and Investigation Facility Policy, Unusual Incident/Injury Report dated 06/11/2025; Staff Certificates of Completion for Abuse & Neglect Prevention; and Reminiscence Neighborhood Residents Emergency Contact Information. On 07/10/2025, Witness 1 (W1) was interviewed. On 08/28/2025, Witness 2 (W2) was interviewed. On 11/20/2025, interviews were conducted, and records were reviewed. Interviews conducted consisted of 1 staff [Staff 2 (S2) was interviewed] and 7 witness interviews [Witness 3 (W3) to Witness 9 (W9) were interviewed]. Records reviewed consisted of pertinent Resident 1’s (R1) records. The investigation revealed the following: Allegation: “Staff did not seek medical attention for resident in care”, it is being alleged that staff did not seek emergency medical attention for R1 on 06/08/2025 which included calling 9-1-1. Interviews conducted revealed the following: Interviews conducted with R2 to R8 revealed the following: 7 out of 7 residents denied the allegation, moreover, residents indicated that if they required medical attention staff would assist them. Interviews conducted with W1 and W3 to W9 revealed the following: 7 out of 8 witnesses denied the allegation and 1 out of 8 witnesses agreed with the allegation. Moreover, 1 out of 8 witnesses indicated that when they observed R1 on 06/08/2025 it seemed as if R1 had been physically assaulted, R1 had bruises on their eyes and face, they observed blood in R1’s room, they were informed by facility staff that R1 had a broken tooth, they took R1 to urgent care (not facility staff). Interviews conducted with S1 to S6 revealed the following: 6 out of 6 staff denied the allegation. Furthermore, staff indicated that on 06/08/2025 the following occurred: Around 8:30 AM facility staff assessed R1 and determined that R1 had a cold sore, R1’s doctor was notified and responsible person. Around 10:45 AM to 11:00 AM R1 was reassessed by Staff 2 (S2) and facility staff observed that R1 had a crack tooth, one tiny tear outside the mouth and one inside the mouth; R1 was asked if they fell but they indicated that they did not fall; R1 could not explain what happened; R1’s room was searched and staff found droplets of blood and concealed wadded up paper towels under the couch; R1’s responsible person was contacted and notified with an update. Staff were unsure how R1 sustained an injury / it was an un-witnessed incident. A theory that staff came up with is that R1 slept on their couch next to their coffee table and R1 fell on the corner of the coffee table. R1’s responsible person came to the facility past 1:00 PM and with the guidance of S2 took R1 to urgent care. Additionally, staff explained that 9-1-1 nor non-emergency ambulance were called because R1 was acting like their normal self, did not express signs of pain, was alert, and did not have a serious life-threatening injury. Moreover, S2 explained that 9-1-1 is called when residents have an un-witnessed fall and head injury. Records reviewed revealed the following: “Statement of Event” written by facility staff on 06/2025 revealed that on 06/08/2025 the following occurred: 5 staff indicated that R1 was assessed by facility staff and R1 was taken to urgent care. Staff 7 (S7) wrote that they assessed R1 around 8:00 AM and “saw open skin (wound) no presence of blood no broken tooth." Just an open white in color open wound…R1 is asked what happened but R1 is unable to answer…no signs of discomfort…around 11:00 AM S2 re-assess R1 and informs S7 that R1 “might had a fall and hit themself on the edge of the table that was same level of the couch.” Staff 8 (S8) wrote that around 8:30 AM they assessed R1 and observed with “a big lump on thei lip (the left) and a bruise on their chin”…R1 was asked if they hurt themselves and R1 indicates no… “the nurse looked at it” and indicates that it looks like a cold sore “since the resident had a cut from the inside of the lip. When the nurse lifted R1’s lip it did hurt the resident. I did notice a chipped tooth as well.” Staff 9 (S9) wrote that they observed R1 at around 9:00 AM and saw that R1’s “right upper lip swollen and a bruise on their right side”…R1 was assessed by facility staff and staff determined that R1 had a cold sore on the right upper lip. Unusual Incident/Injury Report (UIR) dated 06/11/2025 revealed the following: R1 was reported to have a swollen lip and cracked tooth; R1 was evaluated by facility staff and taken to the emergency room. Fax records dated 06/08/2025 revealed the following: facility staff faxed R1’s doctor four times. R1’s Physicians Report revealed the following: R1’s primary diagnosis is Alzheimer’s Dementia. R1’s mental condition is confused and disorientated. Substantiated: Based on interviews and records R1 sustained an un-witnessed fall which resulted in a head injury because R1 was observed with a chipped tooth, a cut inside their mouth, a cut outside their mouth, swollen lip, and bruise on their chin. Additionally, R1’s room was searched and staff found droplets of blood in the room. Also, due to R1’s diagnosis they had difficulties expressing the events that occurred that led to their head injuries and expressing if they were in pain or not. Moreover, staff theorized that R1 slept on their couch and fell on the corner of their coffee table and sustained said injuries. Furthermore, R1 was incorrectly assessed around 8:00 AM with a cold sore and then correctly assessed around 11:00 AM but the facility did not seek emergency medical attention for R1. The preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator, Judith Uy-Villaruz . Investigation consisted of the following: On 07/09/2025, interviews were conducted, a tour of the Reminiscence Neighborhood was conducted, records were gathered. Interviews conducted consisted of 7 resident interviews [Resident 2 (R2) to Resident 8 (R8) were interviewed] and 6 staff interviews [Staff 1 (S1) to Staff 6 (S6) were interviewed]. Facility records were gathered which consisted of Resident Roster dated 07/01/2025; Personnel Report; Abuse, Neglect & Exploitation – Prevention, Reporting and Investigation Facility Policy, Unusual Incident/Injury Report dated 06/11/2025; Staff Certificates of Completion for Abuse & Neglect Prevention; and Reminiscence Neighborhood Residents Emergency Contact Information. On 07/10/2025, Witness 1 (W1) was interviewed. On 08/28/2025, Witness 2 (W2) was interviewed. On 11/20/2025, interviews were conducted, and records were reviewed. Interviews conducted consisted of 1 staff [Staff 2 (S2) was interviewed] and 7 witness interviews [Witness 3 (W3) to Witness 9 (W9) were interviewed]. Records reviewed consisted of pertinent Resident 1’s (R1) records. The investigation revealed the following: Allegation: “Staff did not prevent resident from being hit at the facility by an unknown individual”, it is being alleged that R1 was hit by an unknown individual. Interviews conducted with R2 to R8 revealed the following: 7 out of 7 residents denied the allegation, moreover, residents indicated that no one has ever hit them in the facility. Interviews conducted with W1 to W9 revealed the following: 7 out of 8 witnesses denied the allegation and 1 out of 8 witnesses agreed with the allegation; 8 witnesses indicated that they have never seen a resident being physically hit by another person; W2 goes on to explain that a police investigation was conducted in the facility regarding the allegation and it was unknown if R1 was hit by an individual or if R1 fell on the corner of their coffee table, W2 explains that no individual was arrested due to the allegation and there was not sufficient evidence to indicate that an individual hit R1. Interviews conducted with S1 to S6 revealed the following: 6 out of 6 staff denied the allegation, furthermore, staff indicated that they have not seen or heard that R1 was physically hit by an individual, S1 goes on to explain that the Hermosa Beach Police came to the facility, conducted an investigation, requested video footage of the facility and sign in and sign out records of the facility. Records reviewed of the Hermosa Beach Police Department DR# 25-0001355-Crime / Incident Report dated 06/11/2025 regarding the incident with R1 revealed the following: The Hermosa Beach Police Department were unable to determine if an unknown individual hit R1 or if R1 fell. Based on the department’s interviews and records reviewed this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: “Staff did not report incident to appropriate parties”, it is being alleged that R1’s appropriate parties were not contacted. Interviews conducted with R2 to R8 revealed the following: 7 out of 7 residents denied the allegation, moreover, residents indicated staff contact their family members. Interviews conducted with W1 and W3 to W9 revealed the following: 7 out of 8 witnesses denied the allegation and 1 out of 8 witnesses agreed with the allegation; 7 witnesses indicated that staff contact them when necessary and W1 indicated that facility staff contacted them when R1 had an incident. Interviews conducted with S1 to S6 revealed the following: 6 out of 6 staff denied the allegation, furthermore, staff indicated that R1’s responsible person was contacted and their medical provider. S1 indicated that the facility did not submit an SOC341 Report of Suspected Dependent Adult-Elder Abuse because they did not think nor have evidence that R1 was a victim of elder abuse. Unusual Incident/Injury Report (UIR) dated 06/11/2025 revealed the following: R1 was reported to have a swollen lip and cracked tooth; R1 was evaluated by facility staff and taken to the emergency room; the UIR was faxed to the department. Based on the department’s interviews and records reviewed this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was left with the Administrator, Judith Uy-Villaruz .