complaint·October 7, 2025

In regards to the allegation Staff did not ensure resident received medical care in a timely manner, based on interviews conducted and information gathered 14 of 16 residents stated that staff have been quick to help them. Also stated that staff does a good job with any type of medical attention including visits with the primary care doctor, medication administration and 911 calls and visits to Urgent Care. Resident R2 stated he was found unconscious in his room and the staff responded right away. Resident R13 stated that he broke his ankle at night falling on the sprinkler. Said staff responded right away. Resident R9 stated that he knows of Resident R1. Stated R1 harasses residents and staff. Said R1 jumps into argue for someone else and causes problems. Administrator stated that Resident R17 was at the front desk waiting for Hospice to arrive. Said R1 was diagnosing R17 and that staff doesn't have to explain what they are doing. Said there are HIPPA laws. Staff S1-S3 all stated that R1 was diagnosing R17 and telling R17 that he was having a heart attack. Said that R17 was on Hospice and the protocol is to wait for the Hospice Nurse to tend to R17. Hospice Notes dated 08/15/25 at 9 PM and Hospice checked vitals for R17. States R17 had been given medication for chest pain during the day. Hospice had facility call 911 and R17 was sent to San Gabriel Hospital and admitted on 08/16/25. Discharge instructions to follow-up with your Prmary Care Provider in 1 to 2 weeks. Although the allegation 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 . In regards to the allegation Staff does not ensure residents are spoken to in an appropriate manner, based on interviews conducted and information gathered 14 out of 16 residents stated that staff have not yelled or screamed at residents. Also stated that residents are the ones who scream at staff. Said staff have to use a loud and stern voice. Stated the staff act respectfully and check on them often. Administrator stated that staff didn't tell R1 to stay in her room. Said staff did tell R1 to stay out of other resident's business. Staff S1-S3 all stated they are mandatory reporters and they know that you are not allowed to hold resident's in their room. Said they did ask R1 to stop diagnosing resident's. Special Incident Report dated 08/19/25 and states R17 had chest pain and was taken immediately to USC Arcadia hospital and returned the same day with no new orders. On 08/21/25 SIR indicates that medication prescribed in a Physican's order was administered. R17 still had chest pain and 911 was called immediately. Although the allegation 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 conducted and report issued to Administrator Jacqueline Cortez.