Complaint Investigation Report

**This page is being amended due to confidentiality reasons. This supersedes the report delivered on 11/06/25.**

During the course of the investigation, the following records were also received for R1: Hospice Records from Valley Oaks Hospice, Inc. (dated: 12/01/24-12/16/24) EMS records and 911 recording from Long Beach Fire Department, Death Certificate for R1 from Long Beach Department of Health and Human Services, Home Health Records for R1 from Royal Majesty Home Care, Medical Records from R1’s Gastroenterologist, SoCal Gastroenterology, Hospital Records from St. Mary Medical Center, and Medical Records from Provider 1st R1’s Primary Care Physician, Imaging Records for R1 from St. Mary Medical Center. On 10/15/25, the department requested a copy of the staff roster, resident roster, and the facility menu. The department conducted interviews with witness #1-Witness#15 (W1-W15), staff #1-staff#20 (S1-S20), and residents #2-#7 (R2-R7). The department was unable to interview R1, as R1 passed away on 12/06/24.

The investigation revealed the following: Allegation: Questionable death. It is being alleged that on 11/26/24, R1 sustained a fall in their bedroom resulting in wounds to their arms, hands, and a brain bleed. The resident then passed away on 12/06/24. The department conducted interviews with S1-S20. Of those interviewed, 20 out of 20 staff could not corroborate with the allegation. The department reviewed records. Per Unusual Incident/Injury Report (UIR) dated 11/26/24, on 11/26/24, at around 0536 hours, R1 sustained an unwitnessed fall. S8 observed R1 on the floor of their room near the sofa with flesh wounds on both elbows and redness to the left side of their head. R1’s sofa, recliner, and laundry basket had been moved and were not in their usual location. S8 notified S9 of the incident, who in turn called 911. R1 was then transported to St. Mary Medical Center. According to medical records from St. Mary’s Medical Center Long Beach dated 11/26/24–12/05/24, R1 was admitted on 11/26/24 with a diagnosis of blunt head trauma, fracture of left wrist and an intra-ventricular hemorrhage (IVH). R1 was discharged on 12/05/24 with a diagnoses of blunt head trauma, multiple abrasions, and IVH. R1 was then admitted to Mom & Dad’s House Cottage Facility, and was receiving hospice services from Valley Oaks Hospice. R1 passed away on 12/06/24. Death Report dated 12/06/24 indicates that R1 died of cardiac arrest at Mom and Dad’s House Cottage on 12/06/24. Based on the information gathered, interviews conducted, and records reviewed, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.