R1 resided at this location, prior to licensure when operating unlicensed from approximately 08/30/2024 through 01/17/2025. On 01/17/2025, R1 was hospitalized and discharged to a skilled nursing facility on 01/23/2025 until 03/28/2025. On 03/28/2025, R1 was discharged to another unlicensed location until 04/12/2025. R1 returned to this location on 04/12/2025 and remained until hospitalized on 05/13/2025. The facility’s license was granted on 04/28/2025. On 05/14/2025, the Department received complaint control # 29-AS-20250514101524 which is currently pending investigation.

On 06/23/2025, Investigator Luckett issued a subpoena to the Los Angeles County Department of Medical Examiner requesting R1’s autopsy records.

On 07/07/2025, Investigator Luckett requested any police reports pertaining to R1 from the Los Angeles Police Department (LAPD).

On 07/23/2025, a request for Emergency Medical Services (EMS) records was submitted, and a subpoena for records at Valley Presbyterian Hospital was issued.

On 07/23/2025, Investigator Santana conducted a telephone interview with a LAPD Detective.

On 07/24/2025, a review of EMS records was conducted.

On 08/04/2025, subpoenas for records were issued to Mission Community Hospital during the time period of 09/01/2024 through 05/14/2025, Owl Western Pharmacy, and skilled nursing facility Brier Oak on Sunset.

On 08/05/2025, at approximately 8:05 a.m., a Licensed Vocational Nurse (LVN), (Witness #2) was interviewed. W2 assists sister hospice agency Franklin Hospice. On 05/13/2025, an unknown man from Franklin Hospice contacted W2 and requested W2 visit R1 due to a possible issue with a Foley catheter and R1’s nurse from Franklin Hospice being unavailable. When W2 arrived, the caregiver stated R1 had not taken any medication and was also not taking any fluids. The Foley catheter was in place but there was red tinged urine in the bag. When W2 asked the caregiver where R1’s medication was, the caregiver gave W2 a bin of medication.

Continues on LIC 9099C page 4.

When W2 checked R1’s blood sugar level again, it had only gone down to around 400 mg/dL, and the Medical Director may have instructed them to give additional insulin units, but W2 decided to call 911. A total of four clients were taken to the hospital.

On 08/06/2024, a subpoena for records was submitted to Franklin Hospice for the time period of 09/01/2024 through 05/14/2025.

On 08/07/2025, at approximately 12:50 p.m., an interview was conducted with (Witness #3) at the County of Los Angeles Department of Medical Examiner’s office. W3 said R1’s case became a Medical Examiner case because a detective reported concerns of neglect. W3 determined R1’s cause of death as intracerebral hemorrhage based on a CT scan and autopsy done at their office. R1’s hypertension and type 2 diabetes were listed as other significant conditions because they increase the risk of having a brain bleed, but hypertension is probably the most common cause of stroke. The examination showed R1’s condition was consistent with having had a stroke, and there was no indication of head trauma. W3 found there to be a lot of hemorrhaging in R1’s left brain. The stroke W3 observed was recent relative to the time of her death, but W3 cannot tell if R1 had prior strokes.

Continues on LIC9099C page 5.

On 08/07/2025, Investigator Santana obtained a copy of the R1’s autopsy records. A summary of the records reflect R1 was pronounced dead on 05/28/2025 at 0603 hours (at Valley Presbyterian Hospital). W3 of L.A. County Department of Medical Examiner examined R1’s body on 06/09/2025 and found the cause of death to be intracerebral hemorrhage with other significant conditions of hypertension and type 2 diabetes. The manner of death was found to be natural. Law enforcement expressed concerns that facility conditions were unsanitary, but autopsy did not show physical evidence of neglect or abuse. Examination was performed after two weeks of hospitalization.

Based on hospital records, W3 summarized R1 was initially taken to Mission Community Hospital on 05/13/2025 but was then transferred to Valley Presbyterian Hospital on 05/14/2025. Janet was admitted for altered mentation, sepsis, and UTI. On 5/19/2025, R1 was stabilized and pending discharge but suffered an acute worsening in mental status. A head CT scan showed new focal hypoattenuation in the left MCA territory, and R1 was later found to have suffered a large ischemic stroke and hemorrhagic conversion. Because R1 was not believed to be a surgical candidate, R1 was placed on DNR/DNI comfort care, and R1 was pronounced dead at 0603 hours on 05/28/2025.

On 08/08/2025, at approximately 1:05 p.m., R1’s next of kin (Witness #4) was interviewed. W4 did not have a close relationship with R1 and did not know about R1’s placement or R1’s medical condition but believed R1 had strokes and or seizures as a result of a head injury that occurred 2-3 years ago.

Continues on LIC 9099C page 6.

On 08/11/2025, records from Mission Community Hospital were received. A review revealed R1 was admitted to Mission Community Hospital at 1940 hours on 5/13/2025 with an admitting diagnosis of hyperglycemia. The LAFD EMS Captain advised that the facility knew nothing about R1 and only provided a box full of medications. According to the Captain, R1 would be unable to return to the facility. In the emergency room, R1 had a blood sugar of 475 mg/dL, and was given 10 units of insulin. A head CT scan showed no acute hemorrhage, hydrocephalus, or mass effect. R1 was not able to ambulate but had no apparent distress, pain, or shortness of breath. R1 was found to have dermatitis on the buttock.

R1 was discharged at 0423 hours on 05/14/2025 to Valley Presbyterian Hospital with a blood sugar of 258 mg/dL. Discharge diagnosis was sepsis, with other diagnoses including encephalopathy, type 2 diabetes with hyperglycemia, and hypertension.

On 08/13/2025, at approximately 0835 hours, an email request to LAPD Communications Division for the call for service log at the facility address from 01/01/2025 – 05/13/2025 was submitted.

On 08/13/2025, a review of records from Owl Western Pharmacy revealed Owl Western Pharmacy filled for R1 glipizide, delivered on 3/19/2025; Lantus, delivered on 3/07/2025; and Humulin R, delivered on 3/07/2025. All of these were prescribed by a physician at Maclay Healthcare Center on 3/06/2025.On 08/14/2025, a subpoena for records was submitted to Maclay Healthcare Center.

On 08/15/2025, a review of LAPD’s call for service log revealed a call for service on 04/01/2025 unrelated to R1.

Continues on LIC9099C page 7.

On 08/27/2025, an interview was conducted with Staff #2 (S2) who began working at the facility on 05/01/2025. S2 stated they knew R1 was diabetic but R1 was not receiving insulin. On the morning of 05/13/2025, the NOC staff did not mention anything about R1 but S2 noticed R1’s face was red. When the hospice nurse arrived around noon, R1’s blood sugar was high and insulin was ordered. Between 1600-1700 hours, the insulin was received and a different nurse administered it but R1’s blood sugar was still high so 911 was called.

On 09/04/2025, an interview was conducted with Witness #7 (W7), Medical Director of Franklin Hospice. W7 was not aware R1 should have been taking diabetes medications both oral and by injection until 05/13/2025 when W2 contacted them regarding R1’s blood sugar. W7 advised W2 to give R1 insulin.On 9/04/2025, at approximately 11:20 a.m., R1’s Hospice Nurse / Licensed Vocational Nurse (LVN) Witness #6 (W6) working for Franklin Hospice was interviewed via Facetime video chat. W6 stated when R1 was discharged from the SNF and returned to hospice, the SNF discontinued R1’s diabetes medications and the RN who readmitted R1 followed the orders. As a result, the facility was no longer required to check R1’s blood sugar. W6 did not recall checking R1’s blood sugar during that time.Continues on LIC 9099C page 9.

On 09/05/2025, a review of additional records from Maclay Healthcare Center was conducted. When R1 was discharged from the SNF, discharge documents were sent on 03/28/2025 to A Better Solution home health agency with oral diabetes medications and insulin orders and the resident was transported to an unlicensed location.

On 09/05/2025 an interview was conducted with Witness #5 (W5) who was the referring physician from Franklin Hospice. W5 stated they no longer work for Franklin Hospice as of August 2025. W5 acknowledged their e-signature on R1’s 03/31/2025 but was unsure whether they signed it because of concerning practices. W5 did not know R1’s medication list and no longer had access to that information.

On 09/08/2025, an interview was conducted with Witness #8 (W8). W8 stated R1 was referred to A Better Solutions but when the home health agency went to visit R1 at the unlicensed location they refused services and explained the facility had their own home health or hospice services.

On 09/09/2025, a review of pharmacy records prescribed on 04/03/2025 by W7 reflect no medications for diabetes.

On 9/11/2025, at approximately 12:35 p.m., R1’s attending Physician at Valley Presbyterian Hospital, Witness #9 (W9) was interviewed via Teams video chat. When asked, W9 stated a lack of diabetes medications could have contributed to R1’s stroke. However, damage to arteries occurs over a span of years and does not happen overnight. Continues on LIC 9099C page 10.

Interviews and record review revealed that on 05/13/2025, R1 was hospitalized for hyperglycemia, and a CT scan was performed on R1; there were no acute findings on R1’s head CT scan at that time. After signs of R1’ condition improvement, the hospital was going to discharge R1 to a skilled nursing facility (SNF), however R1 had a change in mentation on 05/19/2025. A CT scan at Valley Presbyterian Hospital showed that R1 likely suffered a stroke, and additional testing showed presence of multiple additional strokes occurring at the hospital. R1 passed away at the hospital on 05/28/2025. R1’s attending physician was unable to say whether R1’s strokes could have been prevented had R1’s diabetes been properly managed.