Complaint Investigation Report

On 2/27/2026, LPA interviewed Client #1 (C1) to Client #4 (C4), and S1 to Staff #3 (S3) over the phone.

On 3/4/2026, LPA interviewed Witness #1 (W1) and Witness #2 (W2) over the phone.

On 3/9/2026, LPA interviewed the Administrator over the phone. C1’s medical reports were obtained.

During today's visit, LPA Konishi obtained the following documents: C1’s Progress Notes from Pasadena Dept of Public Health (DPH). LPA also obtained from Admin, text message notes and emails regarding C1. LPA interviewed the Administrator and W1 and Witness #3 (W3) over the phone.

The investigation revealed the following: in regard to the allegation, “Staff does not ensure to follow up with resident's doctor's appointments.” It is alleged that there have been several requests for an ophthalmology evaluation, chest x-ray, and bloodwork and to date there has been no forward movement. These diagnostic studies are often time sensitive and C1 could potentially be diagnosed with optic neuritis. LPA interviewed C1 that denied the allegation stating that the facility has been following up with his doctor appointments. However, C1 could not recall on needing a ophthalmology evaluation. LPA interviewed one (1) out of two (2) clients that denied the allegation stating that the facility helps ensure following up with the client’s doctor appointments. One (1) out of two (2) clients did not confirm nor deny the allegation since that client schedules and follows up their own doctor appointments. However, both clients stated that the facility helps make sure that the client attends the doctor appointments. LPA attempted but was unable to interview an additional one (1) client since the client did not answer any of the questions. LPA interviewed two (2) out of two (2) witnesses that corroborated with the allegation stating that the facility has not been able to schedule follow-up appointments for C1 since there was a request for C1 to get a ophthalmology referral from C1’s physician on 12/22/2025. One (1) out of two (2) witnesses stated that C1 has not missed any doctor appointments. LPA interviewed Administrator that denied the allegation stating that the facility ensures that C1 and all clients’ doctor appointments are followed up. Three (3) out of three (3) staff could not confirm nor deny the allegation since they stated that the Administrator is responsible for scheduling and following up with C1’s doctor’s appointments. Administrator, three (3) out of three (3) staff stated that C1 has not missed any doctor appointments. The Administrator stated multiple phone calls were made to C1’s physician and the reason for the delay on scheduling the doctor’s appointment to get the ophthalmology evaluation prior was getting no response from the physician’s office and the physician’s office always being busy.