Complaint Investigation Report

(Page 2) Report continued from LIC9099... On 10/23/2024 subpoenaed hospital records from both hospitals where Resident #1 (R1) was hospitalized. On 11/05/2024 and 01/27/2025 received hospital records. On 10/29/2024 LPA Mosley conducted an unannounced subsequent complaint joint visit with North Los Angeles County Regional Center (NLACRC), Quality Assurance Specialist (QAS) Lisseth Carrillo, Registered Nurse (RN) Consultant, Jennifer Castaneda and California Department of Developmental Services, DDS Nurse Consultant III, Dr. Arnold Franco, DNP, FNP-BC. LPA and staff conducted a physical plant tour to ensure there are no immediate health and safety concerns, conducted in person interviews with two (2) staff from 12pm – 1pm. A file review and obtained copies of pertinent documents relevant to the investigation. From 11/18/2024 – 11/20/2024 LPA and NLACRC, QAS corresponded via email and on 11/20/2024 at 3:00p.m. corresponded via video chat. On 05/30/2025 starting at 10:08 a.m. LPA Mosley conducted an unannounced subsequent complaint visit, an entrance interview and a brief physical plant tour were conducted to ensure there are no immediate health and safety concerns, and facility is in compliance with Title 22 Regulations. At 11:57 a.m. conducted an in-person interview with a staff, at 12:12 p.m. conducted a telephonic interview with a former staff and collected copies of pertinent documents relevant to the investigation.

During today’s visit, starting at 11:32 a.m. LPA conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns and facility is in compliance with Title 22 Regulations.

On the allegation Staff did not address a change in residents’ condition in a timely manner it is the concern of the reporting party (RP) that facility staff did not provide appropriate care to address the change in R1’s condition, which resulted in R1 being hospitalized. To investigate this complaint LPA conducted in person interviews, telephonic interviews, file and record review, corresponded via email and video chat, obtained copies of pertinent documents relevant to the investigation.

R1’s incident report revealed that on 10/03/2024, R1 was sent to the hospital at approximately 2:00 a.m. after the night nurse observed that R1 appeared pale. Vital signs were checked, revealing a present pulse and oxygen saturation at 71%. Oxygen was administered per physician’s orders, and 911 was called. CPR was initiated as directed by paramedics, and R1 was transported to Hospital #1 (H1).

Record review revealed that on 10/02/2024 facility staff communicated changes in R1’s condition to the PCP office via email and response time was between 5-7 hours. Report continued on LIC 9099-C PAGE 3...