Complaint Investigation Report

According to medical records, the CT scan showed no acute intracranial hemorrhage, no clavarial fracture, left forehead and left frontal scalp soft tissue edema, and presence of multiple ventricular catheters.

According to staff interviews, staff present during the incident stated the incident did not happen at The Community Compass, Inc. Staff 1 (S1), Staff 2( S2), Staff 3 (S3), and Staff 4 (S4) stated P1 appeared to be at baseline and did not observe any discomfort upon arrival. Staff did not see any participants approaching P1 nor did they see P1 fall. P1 was in his chair during activities. The only time P1 was out of chair was in the changing room. Staff 3 stated, "I went to change [P1], the hat moved back, and I noticed the bump. I continued to change [P1] and called [Staff 1] after I was done."

Due to communication barriers, interviews with Participant 1 and Participant 2 were deemed unsuccessful.

According to an interview with Blue Mountain Transportation, the bus driver stated no incidents occurred on the bus with P1. Individuals who come on the bus are assisted by family members or facility staff.

According to an interview with P1's responsible party, the incident could not have happened anywhere except the Day Program. Responsible Party for P1 did not observe a bump before leaving home and watched P1 get buckled in the bus. Responsible Party stated, "Something happened there, and no one is telling truth. On the incident report, they had [P1] on the schedule at 11:20 AM going to the sensory building. On the daily log, they said [P1] is at the restroom at 11:20 AM."

According to Valley Mountain Regional Center (VMRC) interviews, VMRC was notified of the incident involving P1. VMRC could not determine what may have happened based on what was shown to VMRC.

Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was given to Administrator Richard Skidmore.