Complaint Investigation Report

As a part of the investigation Investigator Ferris obtained copies of Gardena Police Department report, Los Angeles Fire Department report, Harbor UCLA Medical Records, Kaiser Permanente Medical Records which included medical records review, interviews with Administrator #1-2 (A1-A2), Staff #1-5 (S1-S5), Clients #1-5 (C1-C5), Witness #1-3 (W1-W3).

The investigation revealed the following:

Allegation : Resident tested positive for Fentanyl due to staff neglect.

It is alleged that on 04/03/23, Client #1 was admitted to Harbor-UCLA Medical Center where a urinalysis test was conducted and the result was positive for fentanyl and benzodiazepine. On 04/04/23, the client was transferred to Kaiser Permanente Hospital where another urinalysis was conducted and the test was positive for benzodiazepines, but negative for fentanyl. As a part of the investigation LPA conducted a file review which revealed Resident #1 was admitted to 164 th Place on 2/4/23. IB investigator interviewed A1-A2 and 2 or 2 Administrators denied giving C1 Fentanyl & Benzodiazepine. A1 stated C1 does not go out into the community independently and is always supervised by staff. A1 stated C1 usually only has one visitor from Westside Regional Center Supportive Living visit C1. A1 stated R1 was given Haloperidol at the hospital which has been known to cause false positive drug test results. IB investigator interviewed Staff #1-5 and 5 of 5 staff denied giving C1 Fentanyl and Benzodiazepine. IB investigator interviewed Clients #1-5 and 2 or 5 clients denied having any issues at the facility; 3 of 5 clients were unable to answer IB investigator Ferris questions due to their disability.

Per the client’s medication administration record, Harbor-UCLA Medical Center medical records, Kaiser Permanente Hospital – WLA medical records, and L.A. County Fire Department records documented that Client #1 was not prescribed fentanyl or benzodiazepines. Client #1 was not administered fentanyl or benzodiazepines at either hospitals or during the ambulance transportation. Client #1’s Primary Care Physician stated that the client’s prescribed medications would not result in a positive urinalysis test for fentanyl or benzodiazepines. Witness #2 from Westside Regional Center was interviewed and stated, C1 does not leave the facility unsupervised, and did not have a history of purchasing medication(s) without a prescription.