Complaint Investigation Report

Investigation revealed the following: Regarding allegation, Client sustained injuries while in care , it is alleged that C1 returned to their home with unusual bruising on 08/24/22 and 08/25/22. The bruising was observed on C1's right arm and C1 stated in non-verbal gestures that the bruising occurred at their day program. Interviews conducted with Program Director and S1-3 revealed that nothing unusual occurred with C1 on 8/24/22 or 8/25/22 that might have caused C1 to sustain bruising on their right arm. S3 stated that on 08/25/22 as C1 arrived at the program, at approximately 9am, C1 pointed to their right arm. S3 stated that C1 was wearing a shirt with a sleeve and when S3 moved C1's sleeve up, the bruise was noticed in the upper bicep area. S3 reported their observations to S1-2 and the observations were noted down. Interview with S2 revealed that all clients are visually checked upon arrival but removal of clothing items is not performed. S2 stated that staff only learned of C1's bruise until C1 pointed it out to S3 and then also when S2 called C1's home to inform them of another unrelated incident involving C1 at which time the home administrator, Ana Gallegos, reported that she had observed a bruise on C1 on 08/24/22. S1-3 all stated that bruising was not observed on C1 on 8/24/22 and C1 did not point to their right arm. Interviews conducted with SGPRC staff revealed that their investigation did not reveal anything of concern and stated that C1's has behaviors such as running with their eyes closed which lead to C1 bumping into things. Interview with Kendall Guest Home 1 Administrator Ana Gallegos also revealed that C1 runs with their eyes closed and does bump into things when they exhibit such behavior. LPA's review of C1's IPP corroborated the information provided by both SGPRC staff and Kendall Guest Home 1 Administrator regarding C1 running with their eyes closed and running into people and or things. LPA attempted to interview C2-4 but was not able to properly interview them as they are non-verbal clients.

During facility tour, LPA observed clients participating in activities and did not observe anything of concern. LPA observed the facility to be clean during the time of the visit and did not observe any items obstructing any doors or passageways. Based on statements gathered from interviews conducted with staff, SGPRC staff, Kendall Guest Home 1 Administrator and LPA observations, there was not enough supportive evidence to concur with the reported allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED .

Exit interview held. A copy of the report was provided to Program Director Eric Benavidez .