Complaint Investigation Report

Investigation revealed the following: The incident involved the client choking. S1-4 and C2-3 stated that they never observed C1 choking on a chicken salad with a hard shell taco. Staff stated C1 was eating an El Pollo Loco chicken bowl. Clients interviewed stated that they are happy at the facility and staff are providing clients with excellent care and supervision. Staff stated Harbor Regional Center approved one on one care for the C1 for 90 days through a staffing agency which the facility previously used for one on one care for the C1 through Kaiser Permanente. On 10/27/2021, the staffing agency employee sat the C1 at the table, placed his lunch in front of him, and proceeded to walk to the couch to use his cell phone. Two of the STAR staff members were trading off on assisting C1 until they were called to work with the other clients present. STAR staff issued a directive to the staffing agency member to assist the C1 with finishing his meal, which the staffing agency member seemed to take issue with. C1 started to cough, as he routinely does while eating, drawing the attention of STAR staff. The staffing agency employee then approached the C1 and appeared to attempt to assist the client with dislodging the food. Staff stated It is unclear whether this was a necessary action. C1 was not choking, he was fine and did not need to go to the hospital. Staff and clients denied allegations and stated it was false.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the 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 deemed unsubstantiated.

LPA Bunker provided Executive Director Pamela Broderick with copies of LIC9099, LIC9099-C, and LIC811.