Complaint Investigation Report

During this investigation, LPA interviewed Staff #1 (S-1) through Staff #3 (S-3) and Staff #6 (S-6). LPA was unable to interview Staff #4 (S-4) and Staff #5 (S-5) as both no longer work at this facility. However, LPA obtained facility notes entered by S-4 and S-5 pertaining to these incidents. Additionally, San Gabriel Pomona Regional Center also conducted an investigation in regards to these incidents. LPA reviewed C-1’s file and obtained relevant documentation. LPA was unable to interview Client #1 (C-1) through Client #3 (C-3). C-1 and C-2 were at day program and C-3 is currently hospitalized.

Allegation: Lack of supervision resulting in client ingesting a foreign object. Interviews conducted and reviewed documentation revealed that on 01/18/22, C-1 ingested a remote TV battery and on 02/09/22, C-1 ingested a quarter both of which were confirmed by an x-ray examination. According to C-1’s behavioral support plan, C-1 has a “PICA-like behavior: inserting any item that is not meant to be consumed into mouth (may or may not swallow the object)”. Items may include, pieces of plastic, coins, batteries, leaves of a decorative shrubbery, ect.. Per documentation, C-1 requires supervision at all times. Due to lack of supervision, this resulted in C-1 ingesting foreign objects as noted above. Interviews conducted and reviewed documentation corroborates this allegation.

Allegation: Staff not following client's Individualized Behavioral Support Plan. C-1’s behavioral support plans address C-1’s “PICA-like behavior: inserting any item that is not meant to be consumed into mouth (may or may not swallow the object)”. Items may include, pieces of plastic, coins, batteries, leaves of a decorative shrubbery, ect.). C-1’s behavioral support plan provides staff with strategies on how to reduce behavior being addressed, teaching strategies, proactive procedures, reactive procedures and supervision policies and procedures. C-1’s supervision policies and procedures include “staff will not exceed more than eight feet away from C-1 at any time”. Per C-1’s behavioral plan, “staff will always maintain line of sight with C-1”. Interviews conducted and reviewed documentation corroborates this allegation as C-1 ingested foreign items on (2) separate occasions which are noted above.

Based on LPA’s interviews and records review, the preponderance of evidence standard has been met; therefore, the allegations noted above are found to be SUBSTANTIATED.

Deficiency observed and cited per California Code of Regulation Title 22 Division 6. Refer to LIC9099D.

Exit interview held, copy of report and Appeal Rights provided to Marc Marquez