complaint·May 1, 2026

IB investigator Real attempted to interview R1 and Staff #7 (S7), however was unable to because they are both deceased. During today's visit, LPA Zaragoza will be delivering the findings of the investigation. The investigation revealed the following: In regards to the allegation of "Questionable death," it is alleged that R1 passed away on 4/18/2022 due to staff neglect, because R1 had been dropped off at a bus station by S7, and ultimately did not get on the bus which led to their passing. During interviews conducted by IB, it was revealed that a plan was put in place for R1 to travel to Iowa to live with W1, however R1 never got on the bus to arrive at their destination. During interview with S6, they stated that a plan was put in place for R1 to travel by bus to Iowa to live with W1, and all parties agreed to the plan. S6 stated that R1 was to travel by Greyhound bus with R1's trip beginning in California on 3/21/2022, and arriving on 3/23/2022. During interview with W1, they stated went to the Iowa bus station on 3/23/2022 to pick up R1 but they never arrived. W1 stated that about a month later they were notified that R1 was found deceased in Los Angeles. It was determined that R1 did not notify any party of their change in plan to not board the bus. During interview with W2, housing coordinator for R1, they stated that Whittier Glen Assisted Living did notify them of R1's discharge from the facility as required. During record review of R1's death certificate, the cause of death is listed as an accidental drug overdose. In regards to the allegation that " Staff abandoned resident," it is alleged that R1 was abandoned at the bus station because R7 did not ensure that R1 had boarded the bus to travel to Iowa. During interviews conducted by IB, it was revealed that S7 did transport R1 to the bus station for their planned travel to Iowa. During interview with S6, they stated that after S7 did drive R1 to the bus station and made sure that R1 had their tickets to make the travel. S6 stated that S7 left the victim waiting for the bus at the station and returned to the facility. During interview with W1, they stated that they were not comfortable with R1 travelling by themselves to Iowa, but they plan was made anyway, and R1 never arrived at the bus station in Iowa as planned on 3/23/2022. During record review of the facility's transportation policy for scheduled transportation that "unfortunately, the driver may not wait for the resident." Therefore it was determined the facility did not deviate from their plan of operation. Based on statements and interviews conducted with staff, residents, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview held, and a copy of this report was provided. for the allegation " Staff did not ensure residents plan of care was followed." IB investigator Real attempted to interview R1 and Staff #7 (S7), however was unable to because they are both deceased. During today's visit, LPA Zaragoza will be delivering the findings of the investigation. In regards to the allegation that "Staff did not ensure residents plan of care was followed," it was alleged that R1 had lacked capacity and not allowed to leave the facility without assistance according to their physician report, however the facility proceeded with allowing R1 to travel three (3) days by bus to Iowa on their own to live with W1 in March of 2022. During interviews conducted by IB, it was determined that R1 was allowed to travel by themselves to Iowa. During interviews with S6, they stated that according to their appraisal of R1, they displayed a high cognitive level, and did not display any memory related issues during his assessment. S6 stated that R1 was able to communicate their own needs, ambulate on their own with assistant at times, however they were “pretty independent while walking.” During interview with W1, they stated that R1 lost the use of is hand or arm and would forget who they were talking to occasionally. During record review of R1's physician's report, it does indicate that they were unable to leave the facility unsupervised and required supervision. In regards to the allegation that " Staff did not ensure resident was provided medications," it is alleged that R1 was a diabetic who required insulin medication, however they were not provided any of their medications when they were taken to the bus station to relocate to live with W1. During interviews with residents conducted by LPA Zaragoza on 8/4/2025, three (3) out of eight (8) corroborated the allegation. One resident stated that they do not receive their medications on time by staff. Another resident interviewed stated that they need to ask staff for their medications during medication passes or else don't receive them. During interviews with staff, none of them corroborated the allegation. S6 stated that R1 never required insulin or had a physician's order for it, and that is why they were not provided insulin as part of their travel to Iowa. Another staff interviewed stated that they also did not work at the time R1 lived in the facility, however when residents are going out or discharged, they do provide medications to the residents and also document the medications that were provided on a medication release form as proof. During record review of R1's physician report dated 1/27/2022, it describes that R1 was not able to administer their own medications or injections, and that they had a diabetes diagnosis with two (2) different types of insulin listed for their medication/treatment of their diabetes. LPA requested medication records for R1 from the facility, however there is nothing on record. In regards to the allegation that " Staff did not ensure reporting requirements were followed," it is alleged that following R1 did not arrive at their planned destination in Iowa to live with W1 on 3/23/2022 and their passing on 4/18/2022, the facility did not notify Community Care Licensing Division (CCLD) or the law enforcement of these incidents. During interviews with staff, one (1) out of six (6) corroborated the allegation. During interview with S6 who was the administrator of the time, they admitted that they were aware that R1 did not arrive at their destination in Iowa as planned, because they did remain in communication with W1 during this time. Another staff member interviewed who presently works at the facility stated that whenever a resident has an absence or passes away, they always report it to the licensing agency. During record review of incident reports for the facility in 2022, LPA did not discover any incident reports related to the missing status or death for R1. Based on LPA interviews conducted with the residents and staff, the preponderance of evidence standard has been met for the above allegations, therefore the allegation is found to be SUBSTANTIATED . California Code of Regulations Title 22, Division 6, Chapter 8 is being cited on the attached LIC9099-D page. Exit interview was held and a copy of this report was provided.