complaint·November 2, 2023

Upon admission, R1’s physician report dated for May 5, 2023, indicated that R1 was non-ambulatory. R1 began receiving Home Health Services on May 6, 2023, and was discharged from Home Health Services June 5, 2023, due to no further skilled care needed. R1 had several diagnoses such as: Type 2 diabetes mellitus with unspecified complications, major depressive disorder, recurrent, mild unspecified dementia, unspecified severity, history of falling. Interviews conducted with the facility staff stated that R1 liked to walk around the facility but never made any attempts to leave. On June 18, 2023, staff (S1) conducted a room check at 8:30PM and observed R1 was sleeping. S1 returned to R1’s room to conduct a second check between 10:30PM-11:00PM and did not observe R1 in the room. S1 observed that R1’s sliding glass door which led to the street was open. S1 notified staff on duty and La Habra Police Department (LHPD). Per LHPD report dated June 18, 2023, the R1 was found four hours later with facial injuries by Whittier Police Department and taken to the hospital. R1 was hospitalized and upon admission at the hospital, R1 was observed with blunt trauma to face and per-orbital fracture. The following injuries were noted on R1: multiple depressed fractures at the left zygoma, lateral wall of the left orbit, and left maxillary sinus, slightly displaced left orbital floor fracture, left periorbital/facial soft tissue injury, blood products in the left maxillary sinus. It was observed that R1’s face had extensive dark bruising on left temple area, below left eye and on left chin and cheek and multiple scratches/marks around R1’s nose, mouth, chin, and bruising on left side of R1’s nose. Eight days later, the facility submi tted an incident report to Community Care Licensing on June 26, 2023, regarding R1’s June 18, 2023 elopement. On June 23, 2023, an interview was conducted with the facility administrator (AD) who stated that R1 did not have an alarm on their door and was unsure if the facility documented watch logs per resident. The day following the interview, AD provided the Department with a document titled “Watch Log” starting from June 18, 2023, which was the day R1 eloped, and was noted for the times of 6:00AM to 11:00PM. It was observed that there was a staff initial next to every hour. A follow-up interview was conducted with the staff members who had initials on the Watch Log. S1 admitted to never seeing or using a Watch Log, and also denied of initialing a Watch Log document. An interview was conducted with staff 2 (S2) who provided AD the Watch Log, and S2 stated that the log was for the facility’s own personal use and that S2 was unaware it was sent to the Department. S2 then stated the log was made as an example for AD to possibly use in the future. When AD was asked to explain how the log was accidentally sent to the Department, AD stated that AD was unaware if the facility documented room checks, and stated the document was for S2’s personal documentation and was not meant to be disseminated. It was also observed that the document was not accurate because the initials of S1 indicated that S1 checked on R1 between 9:00 PM and 10:00 PM, however an interview was conducted with S1, who denied the of initiating a document. This document was later determined to be a false document that was completed by S2, therefore it became a concern that there may be additional documents that were provided that also may have been falsified. Upon additional investigation involving interviewing R1’s physician, it was determined that R1’s physician’s report dated for May 5, 2023 was falsified. The report had the physician’s name handwritten on it with the exam date of May 5, 2023, however the indicated physician confirmed that the report was not signed by him as R1 had not been evaluated by the physician until June 18, 2023. Per falsified physician report provided by the facility dated May 5, 2023, R1 was reported to only have Mild Cognitive Impairment, is unable to leave the facility unassisted, is non-ambulatory, and that R1 did not have dementia. However, the Pasadena Care Center discharge summary dated for May 4, 2023 and the admission summary from Whittier Hospital dated for June 19, 2023, indicated that the R1 is diagnosed with dementia. During the investigation, evidence shows that the physician’s report was falsified, because the physician denied of ever evaluating R1 on May 5, 2023 and that the physician report the facility presented did not align with the diagnoses specified on the Pasadena Care Center documents. It was determined that R1 did not have a medical exam prior to being admitted to the facility, therefore, the facility was unaware of the level of care R1 required, resulting in R1 eloping and sustaining multiple injuries. Based on interviews which were conducted by the Department, review of documents obtained, and observations, the preponderance of evidence standard has been met, therefore the allegation is SUBSTANTIATED. See LIC9099D for cited deficiencies and immediate civil penalty as per Title 22 Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49. An exit interview was conducted with assistant administrator Jung. A copy of this report, and appeal rights were provided and explained.