Complaint Investigation Report

(MAR) (dated 09/01/2025 through 09/16/2025), Senior Doc documents (dated 08/01/2025, 08/04/2025, and 08/05/2025), and Torrance Police Department card with Case # 250832470 (dated 09/06/2025).

The investigation revealed the following:

Allegation : Due to lack of supervision, resident physically assaulted another resident

The allegation alleges that a resident was assaulted by another resident due to staff not supervising residents.

During the facility visit from 9:15am till 10:30am, LPA observed staff and residents in the Memory Care Unit. LPA observed five (5) care partners and one (1) med tech working. LPA observed in the common area the activity coordinator was conducting activities, and a care partner was observing residents and available if any residents require assistance. LPA observed four (4) care partners escorting residents in and out of the activity room, providing assistance.

During record review, LPA received and reviewed resident R2’s Individualized Service Plan (ISP) dated 08/03/2025, that indicates R2 requires escorting to and from all meals and activities. The ISP indicates R2 receives monitoring and assistance with mood and socialization capabilities due to preferring to be alone. Instructions for support when R2 is observed feeling expressive is to offer the interventions that will support. Additionally on the ISP, it was observed R2 has combative episodes and during their expressive behaviors staff are to redirect R2 in the right direction to prevent future encounters. LPA received and reviewed R2’s Physician’s Report dated 05/20/2025, that indicates R2 has Dementia and is confused and disoriented. LPA received and reviewed staff In-Service logs dated 09/07/2025 regarding Aggressive Behaviors. Additionally, LPA received and reviewed the training logs for Staff S4-S8 and observed four (4) out of four (4) have recent training of “Alzheimer’s Disease and Related Disorders: Psychosocial Needs,” Alzheimer’s Disease and Related Disorders: ADLs and Behaviors,” and “Alzheimer’s Disease and Related Disorders: Behaviors.” LPA received and reviewed an Unusual Incident/Injury Report for an altercation that occurred on 09/06/2025 between R1 and R2. Resident R2 was being escorted to their room from the dining area when their wheel got stuck on the leg of the chair R1 was sitting on. R1 stood up to give more room to R2 when R2 suddenly struck R1. R2 was escorted to their room and R1 was evaluated and provided first aid.

During interviews with Staff S1-S8, were asked if they feel there is enough staff to provide supervision to residents to prevent altercations between residents, eight (8) out of eight (8) stated yes, they have enough staff to provide supervision to prevent altercations. Additionally, during interviews with Staff S1-S8, were asked if they have received training regarding emotional expression, eight (8) out of eight (8) stated they have received training regarding Dementia and emotional expressions.