Complaint Investigation Report

Client C1 was unable to stand up – physician’s report (LIC 602) dated January 11, 2021 stated that client C1 is ambulatory (copy on file), 911 was contacted and client C1 was taken to the ER. At ER x-ray confirmed that client C1 had fractured left ankle and needed surgery. (see copy of SIR) Client C1 was immediately admitted to the hospital. Per staff interviews, facility did not observe any fall or other signs that she was injury. Staff S2 stated that day program had been contacted and had no knowledge of fall or client getting hurt, and bus company had not report any falls. Facility has overnight staff give clients a shower in the mornings, however; there were no observation of injury before the morning of December 23, 2021. Based on statements from staff and documentation provided and reviewed, facility staff can’t explain the sustained injury that client C1 ended with a fractured and need of surgery. (see LIC 809-D)

Department will be requesting an office meting on April 5, 2022 at 13:00 hour at 1450 Neotomas Ave, suite 100, Santa Rosa; to address multiple unexplained injuries to clients in care. Reference complaints # 21-AS-20210414135710 April, 2021; # 21-AS-20211020160657 October, 2021; and # 21-AS-20211229150035 12/2021.

Civil Penalties are also being assessed in the amount of $250 due to a 2nd repeat citation issued for the same sections in less than 12 months. Today's assessment of $250.00 is for the period of 12/22/2021 through 3/25/2022 - Title 22 Regulations # 85075.4

*****Total Civil Penalties issued today in the amount of $250.00.

According with complaint allegation " Resident sustained unexplained injury while in care.” there were related observations made during visit. Based on LPAs' observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.