Complaint Investigation Report

Investigator Zertuche’s record review of Police report on 05/07/24 at approximately 4:00 PM, revealed that there was no evidence of foul play on the death on R1 and Investigator Zertuche’s record review on Los Angeles County’s Coroner report on 05/07/24 at around 5:00 PM revealed that the cause of death was accidental. There was no autopsy and/or toxicology examination done to R1. Further, Investigator’s interview with six (6) staff on 06/06/24, 07/26/24 and 08/21/24 revealed that R1 had no history of drug use for the last six (6) to eight (8) months and no history of drug use while inside the facility. Investigator Zertuche attempted to obtain medical records from the hospital but there was no record of R1 in the hospital.

Regarding the allegation that Illegal drug/substance accessible to client(s) in care, it was alleged that R1 collected money from other clients to buy illegal drugs. Investigator Zertuche’s record review on 06/12/24 revealed that R1 was granted Therapeutic Pass (An integral part of the program, a conditional pass up to twelve (12) hours for the clients to complete therapeutic tasks outside the community signed by the Interdisciplinary team which includes Physicians, conservator and/or case manager) on 02/06/24, 02/17/24 and 03/10/24. LPA’s interview with the administrator on 03/26/24 confirmed that Therapeutic passes are granted to clients who are doing good with the program and R1 was granted on the dates mentioned above. LPA attempted to interview four (4) former clients who reportedly gave money to R1 to buy drugs during R1's Therapeutic pass but all four (4) of them were already discharged from the facility and were unable to be reached. LPA's record review on 05/12/25 also revealed that there was only one incident on 03/13/24 that drug was found with the clients which added to the suspension of Therapeutic Pass and eventual policy revision and strict implementation of the Pass and search and seizure policy of the facility.

Regarding the allegation that Staff is operating out of ratio, it was alleged that the Facility operates at times, 1 staff to 12 clients and that there's not enough staff to care for the clients. LPA's record review on 09/15/24 and 05/12/25 revealed that during the time of the incident the facility had ten (10) clients and six (6) total staff on duty during the shift of the incident.

Based on the information gathered during the course of the investigation, including interviews and record reviews, these allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.