Complaint Investigation Report

Resident Roster (dated 04//08/21), Staff Roster & DSP Work Schedules (dated: 06/01/23), Client #1 Face Sheet (dated: 04/30/18), ID/Emergency Info (dated 03/10/22), Individual Personal Plans (Period: 02/21/23), Medication Administration Records (dated: September & October 2023), Physician’s Orders (dated: 09/01/23 &10/01/23) Admissions Agreements (dated: 05/31/18), Identification/Emergency Information (dated: 03/03/20), Behavioral Support Plans (dated: 03/31/23), Physicians Reports (dated: 07/31/23 & 01/24/23), Appraisal/Needs and Services Plan (dated: 01/10/23), Incident Report (dated: 09/27/23), Body Check Charts (dated: 09/14/23 and 09/27/23) Medical/Specialist Visits (dated: 01/15/23 thru 09/14/23), CDSS Photography Report (dated: 10/18/23), Torrance Memorial Hospital Medical Records (dated: 09/27/23 thru 10/05/23).

The complaint was referred to the California Department of Social Services Investigations Branch and was assigned to investigator (Johnny Canto) which included a review of medical records (dated: 10/18/23 thru 10/05/23); Photography Report (dated: 10/18/23), Law Enforcement Reports (dated: 01/01/22 – 12/07/23). Interviews of medical services personnel (Witness #1-#2); Facility Staff (#A1, #S1, #S2, #S3, #S4 #S5); and Clients (#1, #2).

Allegation #2: Staff failed to respond to the changes in residents’ health in a timely manner.

I t is alleged there were concerns of neglect with client #1(C1) while in care at this facility.

Investigator Johnny Canto conducted interviews with facility staff, physicians, and investigative leads along with medical and facility records revealed that (C1) had numerous visits to the bathroom on 09/27/23 during the night. At 10:30 pm (C1) was seated to urinate for 15-20 minutes, at 11:10 pm (C1) was escorted back to the room and appeared weak and knelt on the bedroom floor, at 12:00 am (C1) appeared weak, leaning on the hallway walls (C1) seated to urinate for 15-20 minutes, (C1) was assisted at 1:00 am for another bathroom visit and remained weak and unbalanced, (C1) remained seated in the toilet for 15-20 minutes, at 3:00 am (C1) was found sitting on the floor bedroom floor (C1) urinated in a seated position for 10 minutes, at 4:00 am(C1) was on found again on the bedroom floor remained weak and unbalanced (C1) remained seated to urinate for 10 minutes.