Complaint Investigation Report
Face Sheet with updated service plan dated 7/29/2025, Physician’s Report dated 12/5/2023 and 4/23/2025. End of shift reports dated for the following dates 8/21/2025, 8/22/2025,8/23/2025, 8/29/2025 and 9/2/2025 for the AM shift. Acacia Hospice of Southern California service plan dated 8/5/2025. LPA also obtained the staff shift schedule for 8/23/2025 and LPA conducted interviews with Staff Members 1-9 (S1-S9), Residents 1-7 (R1-R7) and Witness 1 (W1).
Allegation #1: Staff do not ensure that resident is adequately fed
The investigation revealed the following:
On September 3, 2025, at 10:00 AM, LPA Allen conducted interviews with Staff Members 1 - 9 (S1–S9) and 9 out of 9 staff members stated that residents are adequately fed daily, including the provision of liquids such as water, juice, and milk. Staff also reported that when a resident refuses to eat after three (3) attempts, a meal replacement is provided and documented on end of shift notes.
LPA specifically inquired about Resident 1 (R1) and whether R1 was provided dinner on August 23, 2025, and 9 out of 9 staff members expressed confidence that dinner was provided to R1; however, none could confirm whether R1 consumed the meal.
At 12:00 PM, LPA interviewed Residents 1 - 7 (R1–R7) and 6 out of 7 residents reported that they are provided meals daily, including beverages such as water and juice, and staff encourages them to drink water throughout the day. LPA attempted to interview R1 on three separate occasions; however, R1 was asleep each time. During the visit, LPA observed a clear cup of water with a straw on R1’s bedside, along with a green thermos that appeared to be full when picked up and in reach of the residents’ bed.
On September 4, 2025, at 9:15 AM, LPA attempted another interview with R1. However, R1 was unable to stay on topic or engage in a clear conversation. During this time, LPA observed Staff Member 4 (S4) assisting R1 with eating oatmeal, drinking water, and consuming a bottled Starbucks Vanilla Frappuccino (cold brew).
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction