complaint·February 1, 2022

The investigation revealed the following; Allegations: Staff restrained resident to a bed, Staff are threatening resident’s life and Staff are attempting to steal resident’s money. Based on interviews conducted and records reviewed, LPA discovered that R1's health began deteriorating around the end of December 2021 and beginning of January 2022. R1 had been receiving hospice services since 4/2/21. During R1's stay at Pasadena Villa Senior Living, R1 shared a room with R2 until 1/6/22. Staff began noticing the rapid deterioration in R1's mental state and moved R1 to a private room on 1/6/22. R1 was often observed by staff and his roommate to be disoriented and paranoid. Per statements obtained, R1 would hallucinate and accuse staff (no staff in particular) of strapping him down to his bed, trying to kill him and stealing his money. R1 also accused R2 of trying to kill him and stealing his money. On 12/12/21, Officers Woolford and Goretti, from the Pasadena Police Department responded to Pasadena Villa Senior Living in regards to a call made by R1, stating that "Staff is trying to 187 him". Upon arriving at the facility, the Officers contacted R1 who stated that yesterday morning, a male staff member strapped him down to his bed, they were trying to kill him and take his social security income by throwing him in a river in Long Beach. R1 stated that he was still strapped down to the bed. The Officers inspected R1's bed in person and observed that R1 was not strapped down to his bed and there was no obvious sign of injury. The Officers found no crime had occurred and ended their visit. On 1/28/22, R1 expired while receiving hospice services through Comfort Choice Hospice. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations of "Staff restrained resident to a bed, Staff are threatening resident’s life and Staff are attempting to steal resident’s money". 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. An exit interview was conducted and a copy of this report was provided to the Assistant Administrator.