Complaint Investigation Report, 10/02/2025 — Brookdale Monrovia, Monrovia CA

LPA also obtained copies of Staff #7 (S7) and Staff #8 (S8’s) file documents such as Staff Training, Residents’ Rights Associate Acknowledgement Form, Elder Abuse Reporting Requirements, and Mandated Reporting Requirements.

The investigation revealed the following: In regards to the allegation that: "Staff are not following reporting requirements," it is alleged that the facility staff are not properly reporting an incident of a physical altercation that occurred on 09/08/2025 involving R1 and Resident #3 (R3) was reported by another resident to staff on 09/15/2025. LPA interviewed the Executive Director and Wellness Director denied the allegation stating that the facility reported the incident that occurred of the physical altercation between R1 and R3 on 09/08/2025 was reported to staff on 09/15/2025. Five (5) out of six (6) staff could not confirm nor deny the allegations since they were not aware nor witness that incident. LPA interviewed one (1) out of six (6) staff which stated that the incident of the physical altercation between R1 and R3 that occurred on 09/08/2025 was reported to the Health and Wellness Director on 09/08/2025. LPA also obtained facility Progress Notes dated 09/08/25 which indicate that the staff had knowledge of the physical altercation between R1 and R3 on 09/08/2025 as the incident was reported on the notes. LPA reviewed the Special Incident Report for the incident that occurred on 09/08/2025 which was not submitted by the facility to licensing until 09/18/2025 and not submitted within seven (7) days of the occurrence. There is enough evidence to substantiate.

Based on LPA's interviews conducted with the residents and staff, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 1 are being cited on the attached LIC 9099D.

An exit interview was held with the Executive Director, Danny Vera and a copy of this report and appeal rights were provided.