The details of the complaint alleged that the facility did not take resident (R1) back after they were hospitalized. It was reported that the resident was discharged on 06/12/25 but the facility stated the resident could not come back into the facility because they needed a higher level of care. On 6/19/25, from 9:00am-11:00am, the department interviewed staff (S1-S3) and witness (W1). All staff denied the allegation that Staff are refusing to take the resident back into care. Staff stated that they did not refuse to take the resident back. They stated that they talked to the family member and said that the resident (R1) needed a higher level of care and would require a 1 on 1 caregiver. They state that the condition of the resident had changed and become combative towards staff, residents, and they feared that R1 would injure themselves.

Staff also stated that they told the family member of R1 on 6/12/25, that prior to the resident returning they would need to do a reappraisal of the resident in the hospital. Staff stated that the family member texted them on 6/12/25, stating that R1 won’t have to return to the facility, and that they would be picking up R1s personal belongings the next day. Additionally, they state that the family member wanted them to prepare any final paperwork and issue a refund for 6/14-6/30/2025. Staff stated that they were not given an opportunity to do a reappraisal of the resident and take any further action, given what they would have discovered in the reappraisal. They state the resident was able to come back but a reappraisal needed to be completed first.

The department also interviewed witness (W1), and they stated that they received a phone call from an interested party stating that the facility would not allow the resident to come back unless they had a caregiver that could work 1 on 1 with the resident. They also stated that the resident was supposed to be discharged from Kaiser on 6/12/25 but had it pushed back until 6/13/25 to allow enough time to find another facility. W1 stated that luckily, the resident was admitted to a new facility on 6/13/25.

The department reviewed the Resident Appraisal Information (Dated:04/22/2025), Appraisal/Needs And Service Plan (Dated: 05/05/2025), Unusual Incident/Injury Reports (Dated: 5/11/25,5/19/25, 5/20/25, 5/23/25, 5/30/25, 6/4/25, 6/8/25, 6/9/25), Facility Resident Notes (Dated: 05/07/2025-06/13/2025), Olive View Medical Center Records (Dated: 05/24/2025), Kaiser After Visit Summary (Dated: 6/6/25, 6/8/25), and Text Message Thread (Dated: 06/12/2025 & 06/13/2025) .The department observed from reviewing all documentation that the resident was suffering from a major neurocognitive disorder due to Alzheimer’s dementia disease. The department observed that when the resident was admitted, R1 was mild mannered and compliant.

Report Continued On LIC9099-C

The department reviewed incident reports that document the resident’s change in behavior such as slapping staff members, trying to climb out of their bedroom window, entering other residents’ room and disturbing them, and restricting staffs’ movement in the facility by preventing them from going into other parts of the facility to care for the other residents, by forcibly keeping a door closed, causing staff to call 911 for assistance.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff are refusing to take the resident back into care. 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 because of neglect, therefore the allegation is Unsubstantiated.

No citations were issued.

An exit interview was conducted with Freddie Brown, Caregiver, and a hard copy of this Complaint Investigation Report was provided.