Complaint Investigation Report

The Department concluded a complaint investigation and unsubstantiated the following allegation: Resident sustained unexplained injuries.

Based on the investigation, it was revealed that C1 was taken to Kaiser Permanente Hospital Antioch Emergency Department (ED) on July 6, 2024, due to bruising on his private part. Facility staff did not know how C1 sustained the injury. Review of C1’s medical records received from Kaiser Permanente on May 21, 2025, indicated W4 spoke with C1’s responsible party and S1 and reported that C1 has had previous episodes of agitation, punching and hurting himself and that C1’s injury was possibly self-inflicted.

The Department interviewed W1 on August 27, 2024, who confirmed that C1 has a history of self injurious behaviors including injuries to his private part. During staff interviews, S1, S2, S3, and S4 corroborated W1’s statement that C1 has self injurious behavior where he hits himself hard including his private part. Staff stated that they redirect C1, so he does not hurt himself. Staff indicated that all the other residents at the facility would not hurt C1 due to their limited functioning abilities. Staff denied hurting or causing the injury. The Department interviewed W2 on April 28, 2025. W2 stated an investigation that was also conducted by Adult Protective Services (APS), and based on information gathered, APS finding was unfounded.

Based on the interviews and record review, there is not enough evidence to conclude that C1’s unexplained injury was due to staff neglect or abuse.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED .

Exit interview conducted and a copy of this report provided.