Complaint Investigation Report

On 04/24/2025, Licensing Program Analyst (LPA) Sandra Urena conducted an initial unannounced visit to investigate the allegations listed above. The LPA was greeted by staff and contacted the Administrator. The Administrator Viktorya Hayrapetyan arrived at 11:59 a.m., and the LPA informed them of the reason for the visit. LPA Urena interviewed the Administrator and residents and requested documents pertinent to the investigation from approximately 10:30 a.m. to 01:15 p.m. The Administrator was advised that the complaint was referred to the Investigations Branch (IB). The LPA determined further investigation was needed prior to issuing findings.

Staff neglect resulted in resident sustaining multiple pressure injuries.

On 05/06/2025, from approximately 10:00 a.m. to 11:45 a.m., Investigator Canto and Investigator Rojas conducted interviews with R1, Administrator, residents and Staff #1 (S1) and Staff #2 (S2); on 06/27/2025 from approximately 11:00 a.m. to 11:30 a.m. with residents; on 07/02/2025 at approximately 10:45 a.m. with RP; and on 07/02/2025 from approximately 11:15 a.m. to 11:20 a.m. Investigator Canto attempted to interview Staff #3 (S3) and Staff #4 (S4) via telephone. Investigator Canto left voicemails for S3 and S4, and messages were not returned. In addition, Investigator Canto reviewed Kaiser Permanent Medical Records, Doctor’s Choice Home Health Records, Infinite Home Health Records, and facility’s file documents related to the investigation.

According to R1’s Physician Report, dated 02/19/2025, the primary diagnosis was noted as an unspecified dislocated left shoulder secondary to a fall. R1 was noted to require assistance when transferring to and from bed. R1 was admitted to the facility on 02/19/2025.