Complaint Investigation Report

Investigation Findings: It was reported to the department that a resident, R1 hit another resident, R2, in the nose multiple times and there were no staff present at the time. LPA observed three staff present when LPA arrived. Staff reported that on the day of the incident, R1 was in the facility and planning on joining the other residents for dinner. LPA interviewed R2 who said staff were preparing dinner and setting the dining room when R1 walked over to R2, and out of nowhere, R1 grabbed R2’s face and slapped at R2 hitting R2’s nose. R2 backed away and left the dining room. Staff reported that R1 went to R1’s room. R1 was not available to interview. Staff did not observe the altercation as it happened too quickly. R2 reported it to staff before breakfast the next day. S1, S2 and S3 said R1 is rarely in the facility and leaves very early in the morning so R1 was not around when S1 called the police. R2 and R3 said R1 puts other residents on edge when R1 is in the facility. S1, S2, R1 and R3 say most staff and residents give R1 a lot of space and try to not interact with R1. File review shows R1 has a diagnosis of Schizoaffective and Schizophrenia. R1 has a history of not taking medications and being confrontational. S2 and S3 confirmed there have been four incidents involving R1 since January, in which police have had to come out. S1, S2 and S3 all feel R1’s behavior is getting to a point that R1 may not be able to stay in the facility much longer. Although the facility appears to have enough staff, staff do not have a behavior plan in place for R1 to ensure the other residents are safe from R1’s behavior. The incident occurred due to behavior issues with one resident that is not taking medication and who’s behavior is too erratic and not being mitigated by the facility. Based on interviews and record reviews conducted, the above allegation is substantiated.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED .

Deficiency is cited from Title 22 California Code of Regulations (see LIC9099D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in an additional civil penalty.

Deficiency and plan and proof of correction were discussed with Administrator Shielha Muniz.

Exit interview conducted, Appeal Rights, and a copy this report provided.