L1 confirmed R1 was categorized under a restricted health condition and R1 acknowledged they were able to manage their own medication allowed under the regulation requirements under restricted health. L1 noted that after the assessment, they accepted R1 into care, but upon arrival they became demanding and abusive to staff. L1 advised R1 to bring a ten-day supply of medication, however, R1 arrived with almost none. Furthermore, L1 stated that upon R1’s admission, they were unable to confirm whether R1 had established care with a primary physician, therefore, assisted R1 in arranging care with a doctor affiliated with their health provider. L1 further stated that R1 refused follow-up visits and declined to provide any physician’s name, medical records, or information, insisting that L1 had no right to access such details. L1 noted that this lack of disclosure prevented her from securing an alternate medical placement. L1 reported that R1 independently arranged transportation to their medical treatment sessions. L1 noted that R1 refused to inform staff of the treatment location and at times either canceled the scheduled transport or declined to use it after the vehicle had already arrived. Interviews with 3 of 3 staff corroborated L1’s statements. Staff reported R1’s consistent refusal to take prescribed medication, refusal to permit vital sign monitoring necessary to determine appropriate treatment for a restricted health condition, and the abusive behavior toward staff, did not allow staff to care for R1 as needed.

Interview with Additional Witness 1 (AW1) revealed that R1 frequently refused medication when unable to verify the prescription, noting that R1 specifically requested to see the medication dispensed directly from the original bottle. AW1 further reported that R1 would deny the medication if its shape or color was unfamiliar or unrecognized. AW1 reported that on January 30, 2025, R1 experienced being locked out of the facility returning from a medical appointment. AW1 alleges that R1 began to miss critical medical appointments due to the fear of being evicted.

Interview with Additional Witness 2 (AW2) confirmed that R1 required medical treatment for restricted health condition three times per week. AW2 stated they could not verify how many treatments R1 may have missed. AW2 further confirmed that R1 communicated with a physician shortly after admission to the facility, but was unsure if R1 continued follow-up care. Continued on LIC 9099-C.

A review of records indicates that R1’s medical treatment attendance was consistently poor, prior to admission to Smith Road. Documentation obtained shows numerous missed medical treatment appointments aligning with treatment under Restricted Health Condition, with R1 attending only twice during March and April 2024, and completing just nine treatment sessions across May and June 2024. Documentation obtained further revealed following the January 30, 2025 incident in which R1 was locked out of the facility, dialysis attendance further declined missing scheduled treatments on February 1, 6, 13, and 20, and requested early termination of sessions on February 8, 11, 15, 22, and 27.

Additional records obtained revealed an independent review was conducted by the Riverside County Elder Abuse Forensic Center. Information obtained indicated that R1’s health was already in decline prior to admission at Smith Road Assisted Living, due to severe deconditioning and multiple medical conditions. Furthermore, it was noted that R1’s health continued to deteriorate during their stay, consistent with their overall medical complexity. Documentation corroborated that R1 repeatedly refused care, medication, and supervision, making it impossible to determine whether the facility’s actions contributed to their death. Report concluded the available evidence does not definitively establish a causal link between the facility's actions or omissions and R1’s eventual death.

Based on interviews and record reviews, the allegation that staff neglect resulted in resident death is deemed unsubstantiated. A finding that the complaint is unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted. A copy of this report was provided to caregiver, Edith Campos.