complaint·January 17, 2026

The Investigation Revealed the following: Allegation: Questionable death. It is alleged that R1's death is questionable due to being over medicated. This allegation was investigated by IB Investigator A.Luckett who began the investigation on 2/7/25. On 3/6/25 IB Investigator A.Luckett went in person to the Pasadena Public Health Department and obtained a copy of R1's Death Certificate with a date of death of 2/3/25 and cause of death listed as: Cardiac Arrest and Alzheimers Disease. On 3/11/25 a request for R1's toxicology report was sent. On 12/17/25 IB Investigator A.Luckett received the toxicology report, the laboratory results that were completed on 2/10/25 showed that tests completed on medications were Not Detected. After a thorough review of documents obtained, IB investigator A.Luckett did not see anything unusual or concerning with the cause of death. Based on statements and interviews conducted, review of R1's file, facility records and medical records by IB investigator A.Luckett, there was not enough supportive evidence to concur with the reported allegation. 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. Exit interview held, and a copy of this report was provided.