Complaint Investigation Report

The investigation revealed the following:

Allegation: Facility failed to report incidents between clients.

It is alleged that facility staff did not report injuries on C1 to their responsible party. LPA reviewed C1’s file and it was observed that C1 is not conserved and responsible party listed is Regional Center. LPA spoke to C1's service coordinator and it was explained that the incident was reported to Regional Center within the required time fame. LPA interviewed 3 staff and 3 out of 3 staff denied the above allegation, S2 and S3 stated that the incident was reported to C1 and C2’s family within 24 hours and within 48 hours the incident was reported to Licensing and Regional Center. LPA reviewed Licensing database to confirm date incident was reported to Licensing, incident was dated 10/15/24, licensing received report by 10/16/24, which cooperates with S2 & S3’s statements.

Allegation: Facility staff did not prevent altercations between clients.

It is alleged that during visits at the facility it was observed that C2 was slapping and bullying other clients. LPA reviewed IPP reports for both C1 and C2 and both clients have behaviors that include physical aggression, self injurious behavior and inappropriate social behavior (touching). LPA spoke to responsible parties for both C1 and C2 and it was stated that although both clients exhibit aggressive behaviors and self-injurious behaviors, the facility has shown that they intervene and do what is needed to prevent altercations. LPA interviewed 3 staff and each denied the above allegation, staff stated that although C2 does exhibit bullying behaviors, staff do intervene by separating clients, calming both parties down, continue to observe and monitor clients when they are in close proximity and have behaviorists that work with the clients. LPA reviewed incident reports and there is documentation of incidents where C2 has aggressive behaviors, intervention was done, and responsible parties were notified.

Allegation: Client sustained unexplained bruising while in care due to lack of care and supervision.

It is alleged that in October of 2024 it was reported that C1 had a bruised eye, and within the same month after a visit with C1 additional bruising was observed on C1’s stomach and scratches on C1’s arms. LPA reviewed Incident Reports and this incident was reported to licensing on 10/16/24, according to report intervention was made and C1 was treated with an ice pack. LPA spoke to responsible parties and both stated that staff have a ratio where both clients are closely monitored at all times, however, incidents make occur due to their disability and behaviors.... (Continued on LIC9099-C)