Complaint Investigation Report

Update (dated 12/2024 and 08/2024), Unusual Incident/Injury Report (dated 01/28/2025, 01/04/2025, 11/21/2024) and Staff Training Logs (dated 01/22/2025, 12/06/2024, 08/23/2024, and 08/14/2024). On 02/25/25, 03/21/25, and 04/22/25 The Department conducted interviews with staff #1-5 (S1-S5), on 02/25/25 The Department interviewed clients #1-2 (C1-C2), and on 04/22/25 and 10/21/25 The Department conducted interviews with Witness #1 (W1).

The investigation revealed the following:

Allegation: client sustained an unexplained fracture while in care.

It is alleged that C1 was found to have an unexplained fracture on knee. On 02/25/25, 03/21/25, and 04/22/25 The Department conducted interviews with S1-S5 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above. 5 of 5 staff interviewed reported C1 did not experienced a fall on 11/21/24, however Per 5 of 5 staff interviewed, in November 2024 while C1 transferred from bed to shower chair C1 stubbed toe but did not fall. On 02/25/25 The Department attempted to interview C1 but was unsuccessful due to communication barrios. On 02/25/25 The Department attempted to interview C2, however C2 did not want to interview. On 04/22/25 and 10/21/25 The Department conducted an interview with Witness #1 (W1) regarding the allegation above, per W1 C1 sustained fractures on both legs prior to living at CALIFORNIA MENTOR - 230TH STREET HOME. W1 continued to report that on 01/28/25 attending Doctor at Harbor UCLA Medical Center stated that there was nothing wrong with C1’s knee, however there were some concerns as C1 was visiting the hospital too frequently for injuries.

The Department received and reviewed medical records from Harbor UCLA Medical Center (dated 01/28/2025), records indicated C1 was transferred to the Emergency Department due to swelling to the right knee. C1 had a CT scan that indicated a possible avulsion fracture with a moderate effusion. Additionally, the department received and reviewed records from Advanced Care Orthopedics (02/24/2025) that indicated C1 with an unspecified fracture of right patella. Due to diffusely decrease bone mineralization the x-rays and CT scan evaluation of a fracture was limited. The department received an Unusual Incident/Injury Report on 11/30/2025 regarding an incident that occurred on 11/21/2024 with C1. Per incident report, C1 was taken to Harbor UCLA ER for stubbing their toe while being transferred from the bed to the wheelchair. The Department additionally received and reviewed, staffing Note Summary Report from 11/04/2024 to 02/24/2025 that indicates that on 11/20/2024 C1 stubbed their right middle toe, and on 11/21/2024 C1 was uneasy and was in pain from a fall earlier in the day. It was also noted that on 01/27/2025, C1’s right knee