Complaint Investigation Report

The investigation revealed the following. Regarding Allegation(s): Staff handled clients in a rough manner- It is alleged staff handles residents in a rough manner. Six (6) out of six (6) staff denied this allegation. Three (3) out of three (3) nearby neighbors denied observing this allegation. Due to cognitive impairments, LPA Ramirez was unable to interview three (3) out of four (4) clients present during the visit. LPA Ramirez reviewed four (4) client records. LPA Ramirez observed facility policy on “Hands-Off Policy” that staff signed upon employment. LPA Ramirez observed Special Incident Report (SGPRC Form 641) for client#3 (C3), dated 10/27/2023. LPA Ramirez did not observe SIR to indicate staff handled clients in a rough manner. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Staff did not provide a comfortable and safe environment- It is alleged that facility staff are not providing a comfortable and safe environment for clients by allowing staff to discuss personal life while providing care to clients. Six (6) out of six (6) staff denied this allegation. Due to cognitive impairments, LPA Ramirez was unable to interview three (3) out of four (4) clients present during the visit. LPA Ramirez reviewed six (6) staff records and did not observe any documentation indicating staff were reprimanded for any inappropriate discussions while clients were present. LPA Ramirez observed facility policy on “Rules of Conduct and Progressive Disciplinary Procedure” that staff signed upon employment. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Staff mismanaged clients’ medication- It is alleged that staff do not give clients’ medication when they need it. Six (6) out of six (6) staff denied this allegation. Due to cognitive impairments, LPA Ramirez was unable to interview three (3) out of four (4) clients present during the visit. LPA Ramirez reviewed four (4) client Medication Administration Record (MAR) and clients’ prescribed medications. LPA Ramirez did not observe any discrepancies. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Staff did not seek medical attention for client- It is alleged that staff did not seek medical attention. Six (6) out of six (6) staff denied this allegation. Due to cognitive impairments, LPA Ramirez was unable to interview three (3) out of four (4) clients present during the visit. LPA Ramirez observed SIR for C3 dated 09/29/2023. SIR indicated C3 was experiencing a medical emergency. According to SIR, staff attempted to assist C3 and called 911 to further assist. LPA Ramirez observed facility policy on “Resident Supervision Policy” that staff signed upon employment. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.