Facility Evaluation Report

On this day at around 1:30pm, LPA Luisa Fontanilla arrived at the facility to conduct a case management visit and met with Celso and Minnie Bagaoisan. LPA explained to both the purpose of the visit.

On 6/16/2023, LPA received an unusual incident report dated 5/23/2023 regarding Client 1 (C1) from the Regional Center of the East Bay (RCEB). The facility did not provide an incident report to CCL for this occurrence. The report provided by RCEB indicates that C1 was observed tired and sleepy and unable to respond to prompts to eat. C1 was moved to the couch when C1 started shaking, sat motionless but awake. 911 was called and C1 was transported to the hospital.

While in the hospital, C1’s father observed C1 grabbing right hand with left hand. C1’s right shoulder was swollen and C1 was unable to move it. C1’s father requested the doctor for an x-ray. Results showed C1 sustaining right glenohumeral dislocation and a fracture at the proximal humerus.

On 5/26/2023, C1 needed to undergo immediate surgery to repair the right shoulder dislocation.

During the course of investigation, the Department interviewed clients and staff. Two clients confirmed witnessing C2 pulling C1’s arm while C1 was in the bathroom at around 1900 hours. C3 states Staff 1 (S1) was sleeping when C2 pulled C1’s arm in the bathroom.

On 9/18/2023, the Department interviewed C2. The investigator noted that C2 was excited and energetic while initially speaking with the investigator. When asked about C1 and C1’s injuries, the investigator noticed C2 became defensive and crossed arms.

This is an amended copy of the report issued on 7/31/2025.