Complaint Investigation Report

157208940-8-26-2022-24-AS-MHON-CK4VKK-20221011163029

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

This is an official report of an unannounced visit/investigation of a complaint received in our office on

05/26/2022 and conducted by Evaluator Melinda Medina

COMPLAINT CONTROL NUMBER: 24-AS-20220526130257

Neglect/ lack of care & supervision resulted in residents engaging in physical altercation causing the resident to sustain fractures

On 8/26/22, Licensing Program Analyst (LPA) M. Medina conducted visit to deliver findings on this complaint. LPA met Paul Anderson, Executive Director and stated purpose of visit.

During the course of the investigation, the department conducted interviews and reviewed records. Based on review, on 5/25/22, Resident 1 (R1) and Resident 2 (R2) were in the television room when R1 assaulted R2, resulting in R2 being hospitalized for fractured ribs and pneumothorax requiring a chest tube placement. R1 and R2 had two previous altercations, one of which required R2 to be sent to the hospital. Staff were instructed to supervise residents in the television room however due to insufficient staffing, staff were assisting other residents when the incident occurred.

Based on the above information, the preponderance of evidence standard has been met.

The allegation that lack of supervision resulted in R2 sustaining a fracture while in care is Substantiated.

An immediate civil penalty of $500 is assessed. The issuance of additional civil penalties is pending and currently under review. The details of additional civil penalties will be outlined in a future report to the facility, if any.