Complaint Investigation Report

An investigation was conducted by the Investigations Branch (IB) Investigator John Canto from the

Department of Social Services and completed 05/23/2024 and included the following:

File Review for Client C1 which included obtaining and reviewing documents from the facility which included Special Incident Report's (SIR's), Client Development Evaluation Report (CDER), Admission Agreement, Personnel Schedules, Personnel Contact Information,.

Interviews were conducted with facility staff members, and facility clients.

Medical records from Keck Hospital of USC, and City of Bell Police Calls for Service Documentation were obtained.

Photographs were taken by the IB investigator during the course of the investigation as supportive evidence.

In regards to the allegation Resident sustained unexplained injuries/bruising while in care , based on interviews conducted and information gathered medical records were reviewed and Client C1 sustained a face-forward fall which caused bruising to the face.

Client C1 has the ability to self transfer from wheelchair to bed and vice versa with assistance.

Client C1 was at baseline the morning she sustained her fall.

Facility staff were 15 feet away from Client C1 as she suddenly stood up and fell forward.

Based on information gathered, there is no indication of staff neglecting the needs of clients at the facility.

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.