Complaint Investigation Report

During the course of the investigation it revealed that on 10/9/2019 at 0800 or 0830 hours, Resident 1 told Staff that he hit Resident 2 because he asked for a cigarette. Resident 1 confessed to law enforcement Officer on 10/9/2019 at 1631 hours that Resident 2 asked for a cigarette and that he punched Resident 2 in the mouth one time with his right wrist. Resident 3 who was interviewed on 11/13/2019 at 1240 hours stated that she saw Resident 1 hit someone and he fell down in the parking lot. This resulted in Resident 2 who sustained a head trauma. On 10/9/2019 that same morning, Resident 1 had a fight with his roommate. Resident 1's psychiatrist stated on the day of the incident in the morning of 10/9/2019, Resident 1 admitted to using meth and cannabis since last week and observed him at 1130 hours on the day of the incident buying drugs.

Incident Report dated 8/6/2019 indicated that Resident 1 hit another resident. Warning letter dated 4/9/2018 indicated Resident 1 hit another resident. Incident Report dated 4/8/2018 indicated Resident 1 punched another resident in the face for no reason.

The facility failed to properly evict or find better placement for Resident 1 to avoid incidents. Based on Resident 1's history of hitting residents, recent drug and alcohol use, on date of incident fighting with roommate, observed drinking a beer and admitting to using meth the day before the incident and the seriousness of life threatening injuries sustained by Resident 2 the allegation of lack of care and supervision is deemed Substantiated.

Based on the Investigations Branch observations and interviews which were conducted record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, Title 22, is being cited on the attached LIC 9099 D.

Immediate $500 Civil penalty issued for violation that the department determined resulted in the injury or illness of a person in care.