Complaint Investigation Report

The required 1:1 staff (24/7) for R1 had not been appointed or scheduled. There were three staff on duty at the facility at the time of the incident. The census at the time of the incident was 3. Per the Special Incident Report dated 08/09/2023, submitted by the Administrator, R1 had struck and bitten R2.

Staff on duty S1, attempted to redirect R1 by advising R1 to go to the bedroom. Despite the attempt(s) at redirection by staff 1 (S1) , R1 sustained two red marks on R1’s right leg/knee, and R1’s left wrist was observed to have visible bite marks.

Information obtained during interviews confirmed that R1 had been admitted to the facility without completing a thorough and comprehensive preplacement appraisal and that a behavior plan had not been provided for the purpose of meeting the needs of R1.

Records review also revealed that facility staff did not complete and submit the required SOC 341 Report of Suspected Adult/Elder Abuse as a part of Assembly Bill 40(AB40) requirements.

Based on the information obtained the allegation that Staff did not adequately supervise residents resulting in a resident being physically assaulted by another resident while in care is deemed Substantiated. Exit interview conducted, citation issued , an immediate civil penalty assessed, appeal rights provided and copy of this signed and delivered. A simultaneous Case Management Visit was also conducted to address deficiencies that were identified during the complaint investigation but were not included in the original allegations.