The details of the complaint alleged that the resident (R1) was found lying in bed in deplorable conditions, with roaches crawling on the resident, while unable to move. Subsequently, the resident was transported to Torrance Memorial Hospital on 05/28/25, where the resident was immediately intubated. On 6/11/2025, from 10:00am-2:00pm, the department interviewed staff (S1-S3), witness (W1), and residents (R2-R3) regarding the allegation. R1 could not be interviewed because R1 is in the hospital. 3 of 3 staff denied the allegation that Facility has pests. Staff stated that they have not seen any pests in the facility. They also state that the facility has a pest control company that comes out monthly to service and treat for pests.

The department interviewed residents (R2-R3) about the allegation. R1 could not be interviewed because R1 is in the hospital. 2 of 2 residents that were interviewed denied the allegation that Facility has pests. All residents interviewed stated that they have not seen any pests in their room nor in the facility. The department also interviewed witness (W1) and they stated that they have not seen any pests in the facility while they were visiting the resident.

The department toured the entire facility (resident rooms, kitchen, bathroom etc.) and did not observe any pests or pest activity in the facility. The department reviewed Dewey Pest Control Invoices (Dated: 2/18/25, 4/11/25, 5/14/25) and observed that the facility has regular treatments to prevent pests and pest activity in the facility.

Based on observation, interviews, and records reviewed, there is insufficient evidence to support the allegation that the Facility has pests. 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.

Allegation #2- Facility staff did not seek medical attention for resident in a timely manner.

The details of the complaint alleged that the facility did not seek medical attention for the resident (R1) in a timely manner. It is alleged that the last known wellness checks on the resident was 9 hours prior to the facility calling for emergency assistance for the resident. Subsequently, the resident was transported to Torrance Memorial Hospital on 05/28/2025, where the resident was immediately intubated. On 6/11/2025, from 10:00am-2:00pm, the department interviewed staff (S1-S3), witness (W1), and residents (R2-R3) regarding the allegation. R1 could not be interviewed because R1 is in the hospital. 3 of 3 staff denied the allegation that Facility staff did not seek medical attention for resident in a timely manner. Staff stated that they always check on all the residents to make sure their needs are met such as changing, assisting with activities of daily living, and medication administration. They state that the residents are monitored and checked on consistently.

Report Continued On LIC9099-C

The department reviewed Admission Agreement (Dated:05/08/2025), ID Emergency Information (Dated: 5/8/2025), Physicians Report (Dated: 05/05/2025), Resident Appraisal Information (Dated:05/08/2025), Appraisal/Needs and Service Plan (Dated: 05/08/2025) for resident (R1) and observed that all documentation for the resident was in order. The department also reviewed CPR/First Aid/AED Certificates for the staff and observed that the staff had the required training to provide aide to residents in care, if needed.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Facility staff did not seek medical attention for resident in a timely manner. 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.

Allegation #3- Facility staff did not provide emergency responders information on resident medical history.

The details of the complaint alleged that emergency medical services responded to a 911 call at the facility and when they arrived, staff on scene were unable to provide them with good information of the resident’s (R1) baseline mental status or history of the resident. It is alleged that the staff could not provide basic answers to help with the assessment of the resident. Subsequently, the resident was transported to Torrance Memorial Hospital on 05/28/25, where the resident was immediately intubated. On 6/11/2025, from 10:00am-2:00pm, the department interviewed staff (S1-S3), witness (W1), and residents (R2-R3) regarding the allegation. R1 could not be interviewed because R1 is in the hospital. 3 of 3 staff denied the allegation that Facility staff did not provide emergency responders information on resident medical history. All staff stated that they answered all required questions asked by the responders and gave an information packet on the resident, that included a current physicians report and a list of medications that the resident was prescribed by their physician. They deny that they were not knowledgeable about the resident’s history during the assessment.

Report Continued On LIC9099-C

The department reviewed the Admission Agreement (Dated:05/08/2025), ID Emergency Information (Dated: 5/8/2025), Physicians Report (Dated: 05/05/2025), Resident Appraisal Information (Dated:05/08/2025), Appraisal/Needs and Service Plan (Dated: 05/08/2025) for resident (R1) and observed that the facility has documentation of the resident’s medical history and a service plan to care for the resident.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Facility staff did not provide emergency responders information on resident medical history. 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 Algel Culala, Caregiver, and a hard copy of this Complaint Investigation Report was provided.