Complaint Investigation Report

Due to the clients limited communication skills, LPA was unable to interview client #4 (C4). LPA also interview C2’s responsible party and C1’s San Gabriel Pomona Regional Center service coordinator, who shall be referred to as Witness (W1 and W2). Prior to today’s visit LPA interviewed staff (S4 and S5).

On 9/6/2024 LPA Baptiste spoke to San Gabriel Pomona regional Center Service Coordinator (W1) regarding C1’s care plan.

The investigation reveals the following: Regarding “Resident was verbally/emotionally abused while in care”, it was revealed that S1 and S2 was verbally abusive to C1. The Administrator denied the allegation stating that it is usually C1 who verbally abuse the staff. LPA interviewed a total of 5 staff. 5 out of 5 staff denied the allegation confirming the Administrator’s statement of C1 verbally abusing staff. 2 out of 3 clients denied the allegation. 1 out of 3 clients stated staff are not verbally or emotionally abusive but they are not professional with their responses. LPA interviewed 1 witness and they denied the allegation. LPA reviewed C1’s IPP and confirmed C1 has a history of falsifying allegations.

The investigation reveals the following: Regarding “Staff did not prevent resident from causing self-harm.”, it was revealed that C1 harmed themselves on 7/7/2024. The Administrator confirmed C1 is not on a 1-1 and can lock their bedroom door because of the HCBS final rule. 2 out of 5 staff stated they were on duty when the incident occurred. Both staff confirmed C1 was fine until C1 went into the room. C1 later came out of the room with the cuts and told staff they used the compact mirror from there makeup to do it. 3 out of 5 staff stated they were not at the home during the incident. 2 out of 3 clients confirmed that staff take’s good care of them. 1 out of 3 clients stated staff they were not in the room when they injured themselves. LPA interviewed 1 witness and they confirmed they have no issues with the home. LPA reviewed C1’s IPP and confirmed C1 has a history of self-injurious behaviors. After speaking with C1’s service coordinator, they confirmed it is C1’s personal right to continue to lock their door and leave the facility unattended. They also stated that they are working with the home to assist C1 with their behaviors. LPA also reviewed C1 care plan regarding self-injurious behaviors and observed the facility is following the care plan.

Based on LPA's interviews, investigation revealed: 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 with Ann Fernandez and a copy of this record provided via email.