Complaint Investigation Report

The allegation that “lack of care and supervision resulted in client injury.” Has been substantiated based on the interviews conducted and records reviewed. Facility and hospital records show that on 8/1/21 R1 fell and sustained a fractured wrist and rib. Investigator Patterson was able to interview 1/2 of the staff working that night and was informed that due to inadequate staffing on the night in question, R1 repeatedly left their room in the middle of the night looking for assistance which likely contributed to their fall and subsequent injuries.

Report reviewed, signed and delivered. Exit interview conducted, appeal rights issued, deficiencies cited on 9099(D) page. Immediate Civil Penalty of $500 assessed. The administrator was informed that an enhanced civil penalty might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or(f).