Complaint Investigation Report

Allegation: Staff did not provide adequate supervision to client in care. It has been alleged that on 05/16/25, C-1 had ingested (2) serving packets of Extra Strength Tylenol under the supervision of the Day Program staff. Staff interviews revealed that on 05/16/25, after community outings, C-1 informed staff that C-1 was not feeling well and requested to be given Tylenol (C-1 has a physician’s order on file). Per staff interviews, day program staff, contacted C-1’s residence to inquire if C-1 had been given Tylenol prior to administering the medication to C-1 at day program. Per staff interviews, during this process, C-1 then reported having tightness on their chest and as a result, day program staff called 911 and had C-1 transported to the Emergency Room. Per staff interviews, at the Emergency Room, C-1 informed S-4 that C-1 had taken (6) Tylenol pills prior to coming to day program. S-4 then reported this information to the hospital nurse and day program management. Day program submitted a special incident report to Community Care Licensing (CCL) pertaining to this incident. Per staff interviews, during day program, C-1 receives 1:1 supervision at all times. Per staff interviews, C-1 has a history of fabricating stories and recanting. Per Quality Assurance representative interview, C-1 has changed their story “multiple times” and their findings will most likely be “inconclusive”. Interviews do not corroborate this 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 unsubstantiated.

Exit interview conducted, a copy of the report and appeal rights was provided to Noe Rodriguez.