Health inspection·January 8, 2026

§483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and- (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. §72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 11/24/2025, the California Health Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1), was given a cleaning solution mixed in his food at the facility, the Complainant, after trying a scoop of Resident 1's food immediately started feeling sick and went to the emergency room (ER). The Complainant subsequently took Resident 1 home because she was concerned for his safety at the facility. The Complainant indicated Resident 1's Conservator (a person appointed by a court to manage the financial or personal affairs of someone who is unable to do so themselves due to illness, disability, or other incapacitation) came to the Complainant's home and took Resident 1 back to the facility where the cleaning solution was put in his (Resident 1) food. On 11/25/2025, CDPH conducted an unannounced visit to the facility to investigate the complaint allegations. During the investigation, CDPH determined Resident 1, who had a diagnosis of schizophrenia and who was conserved, was improperly discharged home from the facility with his Family Member (FM), who was not Resident 1's Conservator. The facility failed to: 1. Ensure Resident 1's Responsible Party (RP), who was his Conservator, appointed by the Los Angeles County Office of the Public Guardian, was involved in the development of Resident 1's discharge plan to reflect Resident 1's discharge needs, goals, and treatment preferences. 2. Ensure Resident 1, who was conserved, was not allowed to discharge from the facility in the custody of his FM, who was not designated as his RP. 2. Follow their Policy and Procedure (P/P) titled "Discharge Planning" dated 7/2020 that indicated if the Interdisciplinary team (IDT) and the Attending Physician determine that the resident may be appropriate for discharge, Social Services Staff will coordinate the discussion of discharge with the IDT, the resident, and the RP. These deficient practices resulted in Resident 1 being inappropriately discharged from the facility with his FM, who was not Resident 1's conservator and placed Resident 1 at risk for decline in health and non-continuity of care. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, a 23-year-old male, was admitted to the facility on 9/5/2025 with a diagnosis of schizophrenia. The Face Sheet indicated there were two emergency contacts, but no one was designated as Resident 1's RP or Conservator. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 9/12/2025 indicated Resident 1's cognition was severely impaired, and Resident 1 was dependent on facility staff to complete his activities of daily living (ADL). During a review of Resident 1's Admission Report (a report taken prior to Resident 1 arriving at the facility) dated 9/5/2025, the Admission Report indicated Resident 1 was conserved. A review of Resident 1's Letter of Conservatorship dated 6/27/2025, which was found scanned in the "Miscellaneous" section of Resident 1's medical record, indicated the Los Angeles County Office of the Public Guardian, appointed a conservator of the person and estate of the named conservatee Resident 1, effective 6/11/2025. A review of Resident 1's Physician's Order dated 11/6/2025 indicated Resident 1 could be discharged on 11/7/2025, per Resident 1's FM's request. A review of Resident 1's Discharge Planning Review form dated 11/7/2025 indicated Resident 1's FM was contacted regarding Resident 1's discharge planning and Resident 1 was discharged to his FM's care, per the request of the FM. During an interview on 11/25/2025 at 12:06 p.m., the Social Services Director (SSD) stated she was not aware Resident 1 had a conservator. The SSD stated if she had known Resident 1 had a conservator, she would have communicated with and included the conservator in the discussion regarding discharge plans for Resident 1. The SSD stated she learned Resident 1 had a Conservator when the Conservator called the facility on 11/18/2025 to inquire about Resident 1's status, she then checked Resident 1's medical record and found the conservatorship documents. During an interview on 11/25/2025 at 3:02 p.m., the Director of Nursing (DON) stated facility staff were unaware that Resident 1 had a conservator, apparently the conservator's documents were missed when Resident 1 was admitted to the facility (9/5/2025). The DON stated Resident 1's discharge planning should not have been discussed with Resident 1's FM and Resident 1 should not have been allowed to discharge from the facility with his FM without the Conservator's knowledge or permission. A review of the facility's P/P titled "Discharge Planning" dated 7/2020 indicated if the IDT and the Attending Physician determine that the resident may be appropriate for discharge, Social Services Staff will coordinate the discussion of discharge with the IDT, the resident, and the RP. The facility failed to: 1. Ensure Resident 1's RP, who was his Conservator, appointed by the Los Angeles County Office of the Public Guardian, was involved in the development of Resident 1's discharge plan to reflect Resident 1's discharge needs, goals, and treatment preferences.2. Ensure Resident 1, who was conserved, was not allowed to discharge from the facility in the custody of his FM, who was not designated as his RP. 3. Follow their P/P titled "Discharge Planning" dated 7/2020 that indicated if the IDT and the Attending Physician determine that the resident may be appropriate for discharge, Social Services Staff will coordinate the discussion of discharge with the IDT, the resident, and the RP. These deficient practices resulted in Resident 1 being inappropriately discharged from the facility with his FM, who was not Resident 1's Conservator and placed Resident 1 at risk for decline in health and non-continuity of care. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security and welfare of residents in the facility.