Complaint Investigation Report

The investigation was assigned to Investigation’s Branch (IB) Investigator, Laura Garcia, badge# 225. IB investigator Garcia's investigation consisted of the following: interviews conducted with facility staff#1-4 (S1-S4),C1's relative (CR1), Client#2's relatives #1-2 (CR2-CR3), C1's Service Coordinator (SC), and attempted to interview C1'S physician. IB investigator Garcia also attempted to obtain a copy of hospital medical records, but was unsuccessful without response. C1 was not interviewed due to being non-verbal.

Regarding allegation: Client sustained fracture while in care.

It is alleged that Client#1 (C1) had a medical emergency that resulted in C1 almost falling off the bed and pushed onto the bed by staff to prevent the fall. This resulted in C1 sustaining a fracture. Through interviews conducted with S1-S4, it was noted that the allegation was denied and C1 did not almost fall off the bed. It was stated that on 3/31/22, C1 had a medical emergency at the facility. Upon C1 suffering the medical emergency, staff stayed with C1 until it passed and conducted a body check after that determined C1 was okay. It was discovered through the placement agency's notes that C1's hospital scans revealed C1 suffered from a brittle bone condition. Per interview with CR1, CR1 stated C1's physician advised that C1 is susceptible to injury due to this condition and may have not been related to the "fall" C1 allegedly had at the facility. IB Investigator deemed this allegation to be Unsubstantiated.

Regarding allegation: Staff did not seek timely medical care for client in care.

It is alleged that C1 suffered a medical emergency at the facility that resulted in a fracture an facility staff failed to seek medical care for C1 in a timely manner, though C1 was in pain. Through interviews conducted with S1-S4, it was noted that the allegation was denied. It was stated that on 3/31/22, C1 had a medical emergency at the facility. Upon C1 suffering the medical emergency, staff stayed with C1 until it passed and conducted a body check after. The following day, 4/01/22, C1 was evaluated by S2 and appeared to be fine. C1 went about their day as usual and attended day program. On 4/02/23, S4 noticed that C1 expressed pain and discomfort through grimacing facial expressions. S2 was notified right away and advised to send C1 to the hospital for further evaluation. S1-S4 stated that all events leading to C1 being taken to the hospital were documented and reported right away to CR1, the Licensing Agency, and to C1's SC. IB Investigator Garcia deemed this allegation to be Unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are Unsubstantiated.

Per California Code of Regulations, Title 22, no deficiencies were cited or observed.

An exit interview was conducted with Veronica Flores and a copy of the report was provided.