Complaint Investigation Report

During this investigation, LPA interviewed Former Administrator, Current Administrator, QA, Staff 1 (S1), Staff 3 (S3) and Staff 4 (S4) . S4 interviewed over the phone. LPA was unable to interview Staff 2 (S2) as S2 no longer work at this facility. LPA reviewed C1’s file and obtained relevant documentation. LPA was unable to interview Client 1 (C1) through Client 3 (C3). C1 refused to be interviewed and C2 and C3 were at Day Program at the time of visit. Additionally, San Gabriel Pomona Regional Center also conducted an investigation in regards to these incidents.

Allegation: Staff did not follow the facility IPP resulting in client ingesting a foreign object. Interviews conducted and reviewed documentation revealed that on 12/05/24 C1 swallowed / ingested the metal plug of heating pad and on 01/20/25 C1 swallowed a dime during the outing at the store which confirmed by an x-ray examination. According to C1s IPP, C1 has a “PICA – like behavior: Inserting any item (pieces of plastic, batteries, coins, small metal objects, etc. that is not meant to be consumed into C1’s mouth (may or may not swallow objects)”. Per documentation, C1 requires supervision at all times. LPA review Individual Behavior Support Plan which stated “The 2:1 staffing ratio will be maintained throughout all three shifts (AM, PM, and NOC). During each shift, two staff members will be assigned exclusively to C1, both in the facility and in the community. Staff members must always maintain a line of sight with C1, never exceedingly more than eight feet away from C1. When C1 is in common areas, both staff members should be present and maintain visual contact”. Interviewed QA confirmed that facility staff did not follow C1’s individual Behavior Support Plan and as a result C1 ingested foreign items on 2 separate occasions. Interviews conducted and reviewed documentation corroborates this allegation as C1 ingested foreign items on 2 separate occasions which are noted above.