Complaint Investigation Report

S1, S2, and S4 reported that at approximately 3:00 a.m., a staff member heard a noise coming from the client’s bedroom. Upon entering the room, the staff member found the client on the floor. The overnight staff assisted the client back to bed and noticed the client’s nose was bleeding. They cleaned the nose, and the client returned to sleep. The overnight staff were unable to explain how the client sustained these injuries while under their care.

When the morning staff members observed the client, they noted a black eye on the right side of the client's face and a bleeding nose. Hospital records from Los Alamitos ER (dated 06/26/2025) and Providence Mission Hospital (dated 06/27/2025) documented the injuries, including a closed fracture of the right zygomatic arch.

On 06/27/2025, staff submitted the Special Incident Report (SIR) in accordance with Title 22 Regulations. All three staff members confirmed that they received re-training on Responsibility for Providing Care and Supervision, Reporting Requirements, and relevant policies, procedures, and regulations. Three of the staff members admitted to the allegation.

On 07/02/2025, from 11:00 a.m. to 3:30 p.m., the Department attempted to interview three clients #1-#3 (C1-C3); however, they were non-verbal and unable to respond to any questions.

On 07/02/2025 at 4:00 p.m., the Department conducted an interview with witness #1 (W1). W1 stated that they attempted to interview the client, but the client was non-verbal and unable to answer any questions.

W1 reported that they interviewed staff members, who indicated that the overnight staff heard a noise coming from the client’s bedroom. Upon entering the room, a staff member found the client on the floor, appearing to have fallen out of bed. The overnight staff assisted the client back to bed and noticed that the client’s nose was bleeding. They cleaned the nose, and the client returned to sleep. When the morning staff observed the client, they noted a black eye on the right side of the client’s face and a bleeding nose. The client was subsequently transported to the emergency room by staff for medical evaluation. W1 confirmed that the incident was reported to Harbor Regional Center on 06/26/2025.