Facility Evaluation Report

LPA Ramirez conducted case management deficiencies visit on 03/15/24 stemming from a subsequent complaint investigation dated 3/15/24. Interviews and records reviewed conducted as a result complaint# 28-AS-20240228090034 revealed on 2/19/24, staff document at 5:54 am, staff heard a loud scream come from C1’s room and saw C1 hitting their roommate (C2). Staff intervened and notified the administrator. This licensing agency was not notified of this incident. On 2/20/24, staff documented in the PM shift that upon staffs’ arrival C1 was observed to me seated in the living room and C2 got up and scratched C1. According to staff notes, C1 received a mark on their face and C1 went to their room to isolate themselves after the incident and stood in their room to watch T.V. and listen to records. Staff did not indicate that first aid was provided after visible mark was seen on C1’s face, and staff did not report this incident to this licensing agency. On 6/22/23, LPA Ramirez conducted a case management deficiencies visit and issued a deficiency for staff not rendering first aid to client in care. Interviews with two (2) out of the two (2) staff on duty confirmed that any injury a client receives is documented when staff render first aid. Licensee cleared deficiency on 6/22/23. LPA Ramirez will issue deficiency for reporting requirements and civil penalties for health-related services on repeat offense.

LPA Ramirez reviewed San Gabriel/Pomona Regional Center (SGPRC) Corrective Action Plan (CAP) dated 3/12/24, which revealed S1 texted Administrator Melanie Morris indicating S1 heard C2 scream and found C1 hitting C2 and S1 threatened to call the cops on C1 and made C1 go back to his bed. LPA Ramirez will issue deficiency for personal rights.