Complaint Investigation Report

At 2:30 PM LPA Casillas conducted a physical plant tour. LPA requested copies of updated resident roster and updated LIC 500. Administrator Certificate and bond certificate were previously collected. LPA requested copies of IPP plans for all clients, behavior logs and any other information pertaining to the investigation. There were four (4) clients present in the home during the visit. LPA Casillas previously conducted interviews with Administrator, two (2) staff present and one (1) client out of three (3) that were able to communicate with LPA.

Allegation #1: Staff neglect led to resident sustaining infection wounds.

It is alleged that staff neglect led to Client #1 (C1) sustaining infection wounds. During the investigation LPA Casillas reviewed all SIR’s submitted to Community Care Licensing (CCL) and was able to follow a detailed timeline of how the injury progressed. Based on documentation and interviews with Administrator and two (2) staff, it was discovered that there was no initial wound on C1. The injury was originally reported on 06/01/24 to have some swelling. Upon staff discovering this, immediate emergency room medical attention was sought. As the injury progressed, an additional hospital visit was made on 06/08/24 and on 06/26/24, however facility staff were told that C1’s wounds were not serious. Per Administrator, they did not agree with that diagnosis and the staff took C1 to a different hospital for a second opinion on 06/26/24 when the injury developed an open wound, C1 was provided with antibiotics. On 06/30/24 C1 was admitted to the hospital due to staff observing the wound progress without getting better. On 07/05/24 C1 was released from the hospital back to the facility. Based on observations, record reviews and interviews the facility staff sought the appropriate medical attention for C1’s injury therefore, it is determined that this allegation is Unsubstantiated at this time