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F0921
D

Abandoned Resident Vehicle Left in Disrepair Leads to Fire Hazard

Montebello, California Survey Completed on 05-15-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to maintain a safe and comfortable environment for residents, staff, and visitors by allowing an abandoned car, belonging to a resident, to remain unattended in the facility's parking lot for approximately two years. The car was in a state of disrepair, with flat tires, a broken window, and filled with trash and debris. Multiple staff members, including the Maintenance Manager, Housekeeping Manager, Dietary Supervisor, and Social Worker, observed the car in this condition but did not report it to facility management or take action to have it removed. The Maintenance Manager did not consider the abandoned car as trash or debris, despite facility policy requiring the grounds to be kept free from hazards. On 5/13/2025, the abandoned car caught fire, producing significant smoke and requiring intervention from facility staff, police, and the fire department. The fire was extinguished without reported injuries, but the incident placed 159 residents, staff, and visitors at risk of injury from burns due to the fire hazard. The police determined the fire was an act of arson and towed the vehicle for investigation. Interviews revealed that staff and a family member had been aware of the car's deteriorated and vandalized condition for an extended period but did not escalate the issue. The resident who owned the car had a history of cerebral vascular accident with right-sided hemiplegia and was noted to have moderately impaired cognition on the most recent assessment. At the time of the incident, the resident was not present in the facility, having been transferred to an acute hospital. The car and its keys were not listed in the resident's inventory of personal effects, and there was no documentation of the car being reported as abandoned. Facility policy required maintenance of the grounds in a safe and operable manner, but this was not followed in the case of the abandoned vehicle.

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