Complaint Investigation Report, 01/15/2026 — Sherman Residential Care, Los Angeles CA

The investigation revealed the following:

Allegation: Staff mismanaged client’s medication.

It was reported that Lithium Carbonate was restarted without the responsible person’s knowledge. Per review of Medication Administration Records, (MAR), 2/25 thru 9/25, LPA observed that Lithium Carbonate 300mg was not administered to C1 from 4/1/25 thru 7/30/25. Upon further review, LPA Shirley observed that Lithium Carbonate 300 mg was resumed effective 7/31/25 thru 9/4/25. LPA Shirley observed the After Visit Summary of C1’s visit to Kaiser on 7/29/25 and 7/30/25. The responsible person was not present at these appointments. The summary stated that Lithium Carbonate 300 mg was restarted by the doctor and was relevant to this visit on 7/30/25.

LPA interviewed staff 1 – staff 6 (S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed client 1 – client 3 (C-1 – C-3), of which 2 denied the allegation and 1 confirmed it.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff mismanaged client’s medication.” therefore, the allegation is unsubstantiated.

Allegation: Staff did not ensure that client’s prescribed equipment was properly maintained.

It was reported that C1’s glasses were not properly maintained. Per file review, LPA Shirley observed a Special Incident Report dated 7/3/25, in which C1 was accompanied by 2 staff members to his optometry appointment. Upon entry into the lobby of the building, C1 punched S6 in the face 3 to 4 times and struck an elderly lady who was exiting the building. The Sheriff Department came out and transported C1 to Centinela Hospital. C1 never made it to the appointment. LPA Shirley reviewed vision prescription from rescheduled app on 7/23/25. The glasses were ordered on 7/24/25 per the receipt, ready on 8/16/25 and they were picked up on 8/18/25.

LPA interviewed staff 1 – staff 6 (S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed client 1 – client 3 (C-1 – C-3), in which 2 denied the allegation and 1 was not sure.