Facility Evaluation Report

At approximately 8:45 a.m. on 08/15/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and disclosed the reason for the visit.

Today’s case management visit was conducted after reviewing two (02) incident reports submitted by the facility in which Resident #1 (R1) was admitted to Sherman Oaks Hospital around 10:00 a.m. on 08/02/25 with hip pain and later found unresponsive on the street near Providence-Tarzana Hospital around 2:00 p.m. on the same day.

LPA conducted a record review of pertinent documents, including but not limited to R1’s discharge paperwork and face sheet around 9:40 a.m. on 08/14/25 and interviewed Staff #1 (S1) at approximately 9:50 a.m. on 08/14/25. Interview with S1 confirmed R1 was admitted to the hospital during the morning of 08/02/25 for hip pain. R1 was discharged that same day and returned to the facility. S1 later received a phone call from Providence-Tarzana Hospital noting R1 was found unresponsive near the hospital around 2:00 pm.. Record review indicated that R1 was admitted to the Emergency Room at Sherman Oaks Hospital at 11:16 a.m. on 08/02/25 for hip pain, nausea, vomiting, and opioid withdrawal. Discharge paperwork from Providence- Tarzana Hospital indicated that R1 was admitted for an accidental overdose and diagnosed with an altered mental status and opioid dependence on 08/02/25. Review of R1’s face sheet from 07/31/25 revealed they were already diagnosed with opioid dependence prior to these hospitalizations.

Today, LPA obtained a resident list around 9:00 a.m. which indicated that R1 was in the hospital. LPA called the hospital around 11:45 a.m. this morning to speak with R1. A nurse in the Intensive Care Unit responded and explained that R1 was admitted yesterday, 08/14/25, for their second overdose in two (02) weeks. Interview with Staff #2 (S2) at approximately 2:00 p.m. today revealed that the home health nurse for R1's