Complaint Investigation Report

The Department reviewed hospice care notes dated from January 1, 2026, to March 6, 2026. During this time, Resident #1 (R1) was receiving hospice care. Hospice nurses were contacted and arrived at the facility the same day, accompanied by the responsible party. (R1) was not taken to the hospital; instead, hospice nurses treated (R1) at the facility in the following days. (R1) passed away at the facility five days later, on March 6, 2026, while under the care of the hospice staff. Reports also indicated that (R1) was regularly administered pain medication to alleviate (R1’s) discomfort until (R1’s) passing on March 6.

A further review of Resident #2 (R2's) "Resident Assessment/Service Plan (dated January 2, 2025) indicated that (R2) "may exhibit physically or verbally aggressive behavior" and might present "agitated or anxious behavior." This assessment also highlighted a "change of condition" relative to (R2’s) prior plan, (dated September 20, 2024). It was further revealed that (R2) had been prescribed antipsychotic and antidepressant medication. Nevertheless, (R2’s) Medication Administration Record (dated February 1, 2026 to February 28, 2026) showed that (R2) did not miss any doses in the weeks leading to the incident.

Further review of (R1’s) copy of the County of Los Angeles Death Certificate (dated May 28, 2026) listed "Blunt Trauma" as the cause of death. However, hospice care notes indicated that before the incident on March 1, 2026, (R1) had been diagnosed with "end-stage" Alzheimer's Disease and "advanced" Major Neurocognitive Disorder. It was noted that (R1) was very frail, weak, and debilitated, with poor prognosis. The objective of (R1’s) hospice care treatment was to ensure (R1) had comfort during that time.

The Department reviewed the Culver City Police Station Report (#26001152) and verified that the statements from all parties involved were accurate and consistent with the incident reporting. No charges were filed for elder abuse.

Based on the gathered information, it appeared that the facility was unaware of any previous instances involving Resident #1 and Resident #2 involving physical altercations or assaults and that staff acted promptly when the incident occurred. There is insufficient evidence to corroborate the allegation.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated .

An exit interview was conducted with QUEEN ESTHER BLAKE, and copies of the reports were provided.