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Complaint Investigation Report

Kaiser Behavioral Center West Covina, West Covina08/22/2023Licence 198603289

Census37
Date signed08/22/2023 03:21:12 PM
Name of licensing program analystAlma Gonzalez
Name of licensing program managerWei Siew Ho
The inspector’s account

Investigation revealed the following: Regarding allegation, Staff are not reporting incidents involving client as required, it is alleged that staff did not report concerns regarding bruising that was observed on C5. The bruising that was observed beginning on or around April, June, July and August of 2023, was allegedly reported to facility staff by C5 FM1-2 and staff did not have an explanation regarding how C5 got the bruising and facility staff just stated that they do not know how it happened or that C5 comes to the facility with the bruising. Facility staff did not report any of the incidents were bruising was reported to either San Gabriel Pomona Regional Center or to Community Care Licensing Division. Interview conducted with Lead Supervisor Robert Reyes revealed that staff did not report the incidents regarding C5's bruising to either SGPRC or to CCLD as staff did not witness any incidents in April, June, July or August 2023 and were not aware of how C5 sustained the bruising. Mr. Reyes stated that the only incident that was noted in C5's notes was the bruising reported on 8/11/23 but was not reported to SGPRC or to CCLD. Mr. Reyes stated that on 8/15/23 he had a meeting with SGPRC and C5 FM1-2 and a plan was created to address the concerns. Mr. Reyes stated that the facility will conduct daily body checks of C5 upon arrival and departure of day program and will document and report anything of concern to SGPRC, CCLD and C5 FM1-2. C5 continues to be a client of the day program. LPA did not find any evidence that an incident report was submitted to CCLD or any other applicable agencies within the required time frame regarding any of the reported bruising sustained by C5 for the time frames of April, June, July or August 2023.

Based on LPA review of records and interviews which were conducted, 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 Chapter 3 are being cited on the attached LIC9099D.

Exit interview conducted with Program Manager Vanessa Mejia. A copy of this report and Appeal Rights were provided.

Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction