Facility Evaluation Report

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent case management visit regarding an incident report dated 8/23/21 about a client sustaining a fracture. LPA Mora met with Andrew Thomas (Lead Staff ) and explained the reason for the visit.

The investigation consisted of the following: On 08/27/21, LPA Mora conducted a Health and Safety Check visit. LPA requested a copy of staff and client rosters and conducted a tour of facility and common areas. LPA observed a sufficient supply of perishable and non-perishable foods. LPA observed the clients to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns. On 08/27/21, the Investigation Bureau (IB) accepted the referral for a full investigation.

The investigation revealed the following: regarding allegation “neglect/lack of supervision leading to a client’s fracture”, it is alleged that a staff hit a client with a stick which cause a right arm fracture. IB investigator conducted a full investigation and the investigation consisted of the following: obtained copies of all the medical records for the client, copy of police incident report, and interviewed 3 clients (including the victim), 11 facility staff, facility licensee, 2 regional center representatives, client’s family member, and client’s surgeon. Based on records and interviews conducted, on 08/22/21 morning staff stated that Client 1 (C1) told them that his/her arm hurts and they did a body check and noticed bruises and C1 told them that Staff 1 (S1) hit him/her. On the morning of 08/23/21, staff stated that the pain got worse, and the client was taken to urgent care by the Administrator. At the hospital it was determined that C1 had a fracture. C1’s surgeon diagnosed C1 with a "nightstick" injury, but the surgeon could not exclude self-harm as a cause of C1’s injury. S1 denied any abuse on the client and there was insufficient evidence to determine if S1 caused C1's fracture. Regional center did their own investigation and could not substantiate that S1 cause the injury. The police department did their own investigation and forwarded the report to the District Attorney who dismissed/rejected the charges for S1. (Continued to LIC 9099-C)