Complaint Investigation Report

In regards to the allegation "Staff did not report incidents in a timely manner" it is alleged that the facility did not follow reporting requirements regarding incidents on 11/3/24 and 11/5/24 involving C1. (2) of (3) Staff interviewed corroborated the allegation. (1) of (1) Client interviewed could not corroborate the allegation. Interviews with staff showed there was an incident on 11/3/24 that required a two (2) person standing support for C1 during an incident of physical aggression. There was another incident on 11/5/24 that required C1 to make a visit to the hospital. File review does not show that there were incidents reports provided to Licensing for both dates although both incidents are reportable incidents. Staff interviewed stated to not have created the incident reports for those dates during that month. The issue was also investigated by SGPRC and a Corrective Action Plan (CAP) was created for the facility. This shows the facility failed to meet Licensing reporting requirements as there was no written report provided within 7 days of each incident occurring. Based on LPA observations, interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 1), are being cited on the attached LIC 9099D.

An exit interview was conducted. A copy of this report, Plan of Correction, and appeal rights were discussed and provided.