Allegation: Staff did not prevent residents from attacking other residents

It is being alleged that R1’s walking cane accidentally touched R6 as R1 was getting his food. On 7/22/26, LPA Felisa Shirley reviewed a Shift Report dated 5/31/26 written by S3. S3 reported that R1 was observed being aggressive with R6 as R1’s walking cane hit R6 as he squatted on floor near the dining room. During interview with S7 on 7/22/26, S7 went to R1’s room to assess his condition and determine the cause of his distress. As S7 attempted to gather additional information, R1 became increasingly agitated and began screaming in his room. LPA Shirley interviewed R6 on 7/22/26, regarding the reported altercation. When asked about the incident, the resident stated that they did not recall the altercation and was unable to provide any additional details.

LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 8 out of 8 denied the allegation. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 5 out of 6 denied the allegation. One resident confirmed the allegation and stated that it’s hard to explain, then they ended the interview.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not prevent residents from attacking other residents,” therefore, the allegation is unsubstantiated.

Allegation: Staff filed a false 5150 report on a resident

It is being alleged that R1 was put on a 72-hour 5150 hold. On 7/22/26, LPA Shirley observed an incident report dated 6/3/26, stating that R1 was placed on a 5150 hold by the Psychiatric Emergency Team, (PET) on 6/1/26, by the clinician due to R1 being a danger to others and escalating aggressive behaviors. During file review, LPA Shirley observed the Application for up to 72 Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment dated 6/1/26, due to escalating aggressive behavior and recent attempts to physically assault another resident. LPA Shirley received and reviewed a Shift Report written by S2 on 6/1/26, stating staff reported multiple incidents of unprovoked aggressive behavior from R1. Per interview with the Administrator, S1 on 7/22/26, R1 accidentally hit R6 with his cane and became very upset and aggressive. S1 stated that R1 didn’t want to speak to anyone. R1 would not open his door. R1 called the Hawthorne P. D. S1 stated that she facetimed the clinician. The clinician remained on the phone throughout the entire incident and directly witnessed and observed all events as they occurred. Based on his assessment of the situation, he made the clinical decision to place R1 on a 5150 involuntary psychiatric hold.

Con'd on 9099-C

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff filed a false 5150 report on a resident,” therefore, the allegation is unsubstantiated.

Allegation: Staff do not safeguard residents' personal belongings

It is being alleged that when R1 returned to the facility on 6/8/26, he discovered that his refrigerator was turned off causing his food to spoil. Per interview with R1 on 7/22/26, R1 was away from the facility from 6/1/26 to 6/8/26. Upon returning to the facility, R1 stated that the Administrator, S1, had instructed S8 to turn R1’s refrigerator off in his absence. LPA Shirley interviewed S8 on 7/22/26, and S8 verified that they were not asked to turn R1’s refrigerator off.

LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 8 out of 8 denied the allegation. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 5 out of 6 denied the allegation. One stated again, she didn’t want to talk

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not safeguard residents' personal belongings,” therefore, the allegation is unsubstantiated.

No deficiencies were cited for these allegations.

An exit interview was conducted and a copy of this report was provided to the Administrator, Sandra Lopez.