Complaint Investigation Report

The investigation revealed the following:

In regards to the allegation "Staff did not provide adequate supervision to client in care" , It is alleged that on 5/16/2025, C1 took (2) serving packets of Extra Strength Tylenol under the supervision of a Day Program staff member and that C1 allegedly obtained the ES Tylenol pills during an outing with a one-on-one staff member at the facility. (5) out of (5) staff interviewed denied the allegation. All staff interviewed confirmed that C1 has a one-on-one staff member monitoring them closely and medications are kept secure. On May 16, 2025, day program staff reported to the facility that C1 was taken to the ER for chest pains after admitting to taking (4) packets of 500mg ES Tylenol pills in the day program’s restroom. At the ER, day program staff found (2) more packets in C1's backpack. When S5 arrived at the ER, C1 claimed to have obtained the Tylenol from a trip with day program staff and not the facility staff. However, other staff interviewed stated C1 said they got the pills from a man in the transportation van. LPA attempted to interview C1 three times, but C1 refused to be interviewed. (2) clients interviewed were unaware of the incident and felt there was enough staff to supervise and meet their needs. Clients interviewed also indicated they like the staff and feel comfortable at the facility. LPA observed that the medications were stored safely and were inaccessible to clients. Medication Administration Record (MAR) for C1 was reviewed and showed no ES Tylenol was given between 05/05/2025 and 05/16/2025. Additional records reviewed (IBSP 04/15/2025) indicated C1 has a history of fabricating stories and later changing them. Although the Regional Center has not yet finished its report, the SC and QA representatives agreed that their findings are likely to be "inconclusive" due to C1's repeated changes in their story.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is U NSUBSTANTIATED.

Exit interview was held, and a copy of this report was provided to Jacob Candias, Assistant Administrator.