Complaint Investigation Report

On 11/16/2021, at approximately 9:30am, Licensing Program Analyst (LPA), Sandra Urena arrived at the facility to conduct an unannounced investigation visit regarding the allegations above. The caregiver greeted LPA Urena and stated that the Licensee, Pacita Serrano, was not present. The caregiver proceeded to call the Licensee to inform them of the visit. At 9:45 a.m., LPA Urena spoke with the Licensee on the phone and explained the reason for today’s visit. LPA Urena obtained and reviewed records from 9:55 a.m. to 10:30 a.m.; and, conducted interviews with staff and residents from 10:35 a.m. to 11:20 a.m.

On the allegation of ‘Unexplained death’, it is alleged that the Resident #1(R1) died due to the neglect by the facility staff. It was expressed that when the paramedics were called, R1 was had already passed. Furthermore, the complainant stated that the paramedics were called because ‘the patient had a stomach problem’. To investigate this allegation the LPA conducted staff interviews, resident interviews, and reviewed pertinent records to the allegation.

On 11/16/2021, at approximately 10:35 a.m., the LPA interviewed the Staff #1(S1). S1 stated the following: On 11/11/2021, at approximately 11:45 p.m., S1 stated that they were getting ready for bed, first by going to the bathroom, when S1 heard a scream and heard Resident # 1(R1), say “Mama, mama”. S1 stated that they finished using the bathroom, then went to look into the R1’s room. At this point, S1 found R1’s mouth open and eyes were rolled back towards the top of R1’s head. S1 stated that the R1, ‘was dead’. S1 stated that S1 checked for R1’s pulse and there was no pulse. S1 stated that they didn’t perform CPR because R1 was dead with their mouth open. The S1 stated that they proceeded to go look for Resident #2 (R2) to get the R2’s assistance, because the R2 spoke the same language as R1. Both S1 and R2 went to see R1 in the bedroom, and at this time R2 stated to S1, “R1 is dead”. LPA Urena asked the S1 if the R1 had complained of pain or not feeling well on 11/11/2021? S1 stated, ‘No, I took R1’s temperature and the R1 was ok, no fever’. Per S1, they proceeded to call 9-1-1, then the administrator, Pacita Serrano.

On 11/16/2021 at approximately 11:10 a.m., the LPA interviewed the administrator about the incident. The administrator stated that S1 called them with the news of R1’s death. The following is a timeline about the events as explained by the administrator. At approximately 12:16 a.m., the administrator received a call from S1 to inform them about R1’ death. Per the administrator, S1 stated the following, ‘R1 is dead, they are not breathing’. At 1:10 a.m., the administrator called the Los Angeles Regional Center to report the death of R1. At 1:40 a.m., the Los Angeles Police Department (LAPD) arrived and took a report. At 3:00 a.m., the administrator contacted responsible party for R1. At 4:50 a.m., the funeral home arrived to pick up R1’s body.