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Ombudsman/Attorney Partnership Leads to
Better-Late-Than-Never DPH Enforcement


In an extraordinary success for a unique “public-private partnership” of Ombudsman and attorneys, a couple of fruitless Department of Public Health (DPH) nursing home complaints were recently turned into high-level citations and fines.

In the first complaint, a female resident of Oakpark Healthcare Center of Tujunga was drugged with multiple psychotropic drugs to sedate her because she was crying out “help me.” The resident had a gangrenous bed sore that led to her death; nonetheless, the facility failed to investigate if the resident's "help me" cries were related to the excruciating pain she must have felt. Instead, her cries were miscast as a psychiatric issue to be treated with chemical restraints. Faced with these facts, DPH initially issued a single trifling deficiency for failing to properly treat the resident's bed sore. The deficiency was not accompanied by a monetary fine and the supportive findings do not mention the resident’s pain, her cries of “help me," or the use of multiple drugs to chemically restrain her.

In the second complaint, a female resident of Holiday Manor Care Center in Winnetka died following a broken hip suffered from a fall in the facility. The resident had a significant risk of falls and had fallen before but her care plan was not updated and her records did not show much evidence of fall prevention efforts or implementation of the efforts that had been considered. In its initial review of the case, DPH determined the facility had not violated any regulations or care standards. No deficiency, citation, or fine was levied.

Fortunately, the Los Angeles County long-term care Ombudsman program was aware of both of these cases and outraged by the lack of DPH enforcement action in light of the of the extreme abuse and neglect. The Ombudsman program, run by WISE and Healthy Aging, was paired with local elder abuse law offices, Moran Law of Santa Ana and Johnson Moore, Trial Attorneys of Thousand Oaks, to prepare appeals with DPH. Though DPH took more than two years before deciding the appeals, in August 2015 it finally issued a AA citation with a $75,000 fine in the Oakpark case and a A citation with a $20,000 fine in the Holiday Manor case.

Kudos to Hilda Estrada and Molly Davies of WISE and Healthy Aging and attorneys Alex Feldman of Moran Law and Greg Johnson of Johnson Moore for their work to bring justice in these cases. The collaboration between Ombudsman programs and elder abuse attorneys with experience in nursing home cases is one that has long been overlooked but provides many opportunities for good work.

Read the initial Holiday Manor enforcement action
Read the subsequent Holiday Manor citation

Read the initial Oak Park enforcement action
Read the subsequent Oak Park citation