Complaint Investigation Report

The Investigation Revealed the Following:

Allegation: Staff did not provide medical attention in a timely manner.

It is alleged that on 11/26/25 C1 was not taken to the hospital in a timely manner, while being in severe pain from a dental procedure that was done earlier in the day. LPA reviewed discharge paperwork from the emergency room dated 11/27/25 at 3:08am. Per interviews with 6 staff 5 out of the 6 staff observed C1 being uncomfortable profusely rubbing their face and spitting out an excessive amount of blood and saliva from 1pm till night shift arrived at 10pm. Per interview with S1 it was revealed that C1 had a dental appointment in the morning of 11/26/25 where C1s mom took them, C1 was in pain after the procedure and C1s mom took C1 to urgent care where medical treatment was not able to be done due to C1s behaviors/disability. S1 admitted to leaving a note for the night shift staff to take C1 to the hospital and stated they left the facility around 9pm that evening. Interviews with S3 and S5 stated at 2pm the note for the night shift staff was observed on the table. Interviews with S3-S6 revealed that the instructed note that said “NOC, Staff please take C1 to ER. One staff stay and one can take C1 in please”, and did not understand why upper management was waiting till the night staff arrived to take C1 to the ER knowing the visit was needed since approximately 2pm when the note was first observed. LPA spoke with C1 during the initial visit and they stated they are no longer in pain and showed LPA that teeth had been pulled out, C1 had redness around the mouth but did not appear to be in any pain or discomfort at the time of visit.

Based on LPAs observations and interviews which were conducted, and review of client files, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC9099-D. Exit interview held, and a copy of this report and appeal rights were provided.