Complaint Investigation Report

LPA also obtained the staff and client roster. Administrator will send R1’s updated physician’s report to the LPA by fax or email. No health and safety concerns were observed.

During today's visit, LPAs obtained the following documents: staff and client rosters. LPAs interviewed Administrator.

The investigation revealed the following: in regard to the allegation, “Staff did not provide the appropriate paperwork to medical personnel” It is alleged that on 05/13/2025, the facility needed to provide additional documents since the facility only provided a face sheet and the MARs (Medication Administration Record) with C1 to the hospital. LPAs were not able to obtain any other details from the Reporting Party. LPAs interviewed the Administrator that denied the allegation stating that sufficient pertinent forms were sent with C1 to the ER personnel. Administrator stated that the facility protocol is provide face sheet, MAR with client and follow up with the hospital to provide additional information. LPAs observed the following forms that per administrator were sent with the C1 to the ER personnel which include the face sheet and MARs. LPAs reviewed Title 22 Regulations in which there are no written requirement on specific documents to be sent from the facility to the ER. There is not enough sufficient evidence to substantiate.

Allegation: “Staff did not seek timely medical care for resident” It is alleged that on 05/13/2025, C1 complained of pain and C1 was examined at various hospitals and eventually was treated at one of the hospitals. This allegation was investigated by the Investigation Bureau (IB) and was assigned to Investigator Douglas. LPAs reviewed IB interviews which revealed the following: During the course of the investigation, it was revealed that on 05/13/2025, C1 complained to staff that C1 was experiencing pain all over C1’s body. C1 was sent to Pomona Valley Hospital by staff that same day (05/13/2025). Per x-rays performed, no acute fractures were discovered. C1 returned to the facility that same day (05/13/2025). However, C1 again complained of pain on 05/16/2025. C1 was sent to Los Angeles Community Hospital by staff that same day (05/16/2025). C1 remained at Los Angeles Community Hospital until 05/24/2025, when C1 was discharged back to the facility. When C1 returned to the facility on 05/24/2025, C1 immediately requested to be sent to Queen of the Valley Hospital late that evening on 05/24/2025 (at approximately 2300 hours). However, when C1 arrived at Queen of the Valley Hospital (at approximately 2330 hours), medical staff at Queen of the Valley Hospital then transferred C1 to Pomona Valley Hospital early morning on 05/25/2025. C1 remained at Pomona Valley Hospital until 06/08/2025, when C1 was discharged and returned to the facility.