Complaint Investigation Report

(Page 2) Report continued from LIC9099...

From 11/18/2024 – 11/20/2024 LPA and North Los Angeles County Regional Center (NLACRC), Quality Assurance Specialist (QAS) Lisseth Carrillo 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 member, at 12:12 p.m. conducted a telephonic interview with a former staff member and collected copies of pertinent documents relevant to the investigation. In relation to another investigation conducted on 10/15/2024, on 10/23/2024 LPA subpoenaed hospital records from both hospitals where Resident #1 (R1) was hospitalized. On 11/05/2024 and 01/27/2025 received hospital records. Additionally, on 11/22/2024, Investigator Flores obtained a copy of R1’s death certificate.

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 QUESTIONABLE DEATH, it is the concern of the reporting party (RP) that facility staff did not properly care for Resident #1 (R1) resulting in death. 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.

Interview with the Administrator revealed that staff were monitoring R1’s residuals to assess digestion via their G-tube. Feedings were withheld on three (3) occasions due to residuals exceeding 100cc. R1’s PCP was contacted following the first incident and advised staff to adhere to the prescribed dietary orders. On 10/02/2024 at approximately 2:00 a.m., R1 was sent to the hospital after the night nurse observed that R1 appeared pale and had an oxygen saturation level of 87%. CPR was initiated due to a low pulse, and 911 was called. R1 was transported to Hospital #1 (H1) and admitted for respiratory failure. Intubation attempts were unsuccessful, and R1 experienced a gastrointestinal bleed. R1 was subsequently placed on high-flow oxygen. Additionally, the Administrator reported receiving only one (1) update from H1. Despite repeated follow-up calls, no further information was provided due to lack of authorization. As of 10/16/2024, no additional updates had been received from H1. Report continued on LIC 9099-C PAGE 3...