Complaint Investigation Report

On 09/12/2025, LPA Arroyo conducted the initial complaint visit. During the initial visit, between 01:55 p.m. and 02:45 p.m., the LPA conducted a physical plant tour with staff, interviewed one staff member, conducted a resident file review, and obtained copies of pertinent documents relevant to the investigation.

On 09/24/2025, at approximately 10:24 a.m., IB Investigator conducted an interview with R1. Additional interviews were conducted on 10/28/2025 at approximately 10:49 a.m. and 11:06 a.m. with two staff members, and at approximately 11:19 a.m. with the Administrator. On 01/14/2026, at approximately 9:05 a.m., IB Investigator interviewed R1’s family member. Further interviews were conducted on 01/16/2026 at approximately 9:15 a.m. and 10:07 a.m. with representatives from Foundation Aiding the Elder (FATE), and at approximately 10:59 a.m. with R1’s family member. On 02/12/2026, at approximately 5:25 p.m., IB Investigator interviewed the former facility Administrator. On 03/13/2026, interviews were conducted at approximately 10:30 a.m. and 11:11 a.m. with former facility administrators, and at approximately 11:27 a.m. with a Highland Hospice nurse. Attempted interviews were also made on 02/27/2026, at approximately 10:13 a.m., and on 03/13/2026, at approximately 10:10 a.m., with R1’s Primary Care Physician (PCP). Additional attempted interviews were conducted on 03/03/2026, at approximately 8:07 a.m., and on 03/13/2026, at approximately 10:06 a.m., with the hospital’s Licensed Clinical Social Worker (LCSW). On 03/13/2026, attempted interviews were also conducted at approximately 10:14 a.m. with an APS nurse; at approximately 10:17 a.m. with an APS Social Worker; at approximately 10:52 a.m. with a representative from Integrity Care Management; and at approximately 10:55 a.m. and 11:36 a.m. with a representative from Los Robles Home Health. IB Investigator also requested and reviewed copies of St. John’s Hospital medical records, Kaiser Medical Center medical records, and facility file documents related to the investigation.

Record review and interviews conducted revealed that R1 was admitted to the facility on 06/12/2021. A review of R1’s Physician’s Report, dated 07/30/2025, listed R1’s primary diagnoses as major neurocognitive disorder due to an unspecified disease, mild, without behavioral disturbance; atherosclerosis of the aorta; hyperthyroidism; inflammatory polyarthritis; migraine; osteoporosis; and dermatitis.

The report indicated that R1 was able to communicate and follow directions/instructions and did not exhibit behavioral expressions such as disorientation, lack of hazard awareness, lack of impulse control, unsafe wandering, elopement, expressions of frustration, or hallucinations.