3951 East Blvd, Los Angeles, CA 90066
Citation Number: 910006747
Citation Date: 12/28/2009
Violation Date: 1/7/2010
On 3/19/08, a 39-year-old resident was pronounced dead after being found with a rope around her neck, hanging from a tree on a patio that was locked and supposed to be off limits to residents. The mentally ill resident suffered from psychosis and schizophrenia and had a history of suicide attempts. On the day of her death, the resident had reported overwhelming feelings of isolation and loneliness. Her care plan called for staff to check on her every 15 minutes. At the time the resident was found hanging from the tree, her whereabouts were unknown for approximately 50 minutes. The facility was cited because it failed to continuously monitor the resident in accordance with her care plan.