Complaint·February 19, 2026

The investigation revealed the following: Allegation: Staff did not assist resident with incontinence care needs in a timely manner. It is being reported that 911 dispatch was called to this facility. During Emergency Staff assessment of R1 the resident was found to be drenched in their urine. On 2/10/26, LPA Felisa Shirley reviewed R1’s Physician Report dated, 2/4/25 and observed that R1 is not able to care for his own toileting needs. During review of the November, 2025 Incontinence Tracking sheet, LPA Shirley noted that on 11/22/25, R1 was serviced every 2 hours by initialed staff until the time he was transferred to Cedars Sinai Medical Center. Per interview with S5 on 12/2/25 the residents are changed every two hours and as needed. LPA Shirley interviewed S-1 on 12/2/25 and was told that R1 is sometimes able to remove the diaper on his own to go to the bathroom. LPA interviewed staff 1 – staff 5(S-1 – S-5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed resident 1 – resident 5(R1 – R5). Of those who interviewed 3 out of 5 denied the allegation. Two residents use the bathroom on their own. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not assist resident with incontinence care needs in a timely manner,” therefore, the allegation is unsubstantiated. Allegation: Staff did not seek timely medical attention for resident. It is being reported that R1 was ill due to the negligence of facility staff. On 2/10/26, LPA Shirley reviewed the medical records from Cedars Sinai stating date of arrival, 11/22/25 R1’s diagnosis was dehydration. During review of requested unusual incident report dated 11/24/25, LPA Shirley noted that R1 told staff that he was not feeling well and he requested to go to the hospital. LPA Shirley Con'd on 9099-C interviewed S2 and S3 on 12/2/25. Both staff stated that upon arrival to R1’s room on 11/22/25, R1 appeared to be ill so S2 called 911. LPA interviewed staff 1 – staff 5(S-1 – S-5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed resident 1 – resident 5(R1 – R5). Of those who interviewed 5 out of 5 denied the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not seek timely medical attention for resident,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Administrator Assistant, Cesilia Torres.