Complaint Investigation Report

It is indicated that R1 had sustained an injury from an unwitnessed fall at approximately 1:50pm and appropriate emergency medical attention was not contacted until 3:24pm. Based on LPAs interviews and record review R1 had a large amount of blood soaking through applied several gauze pads and nurse and Officer informed either verbally or in report that R1s skull was visible due to injury.

In addition, Administrator’s statements to Marin Central Police Authority and LPA Hansen confirm Administrator did not choose to seek emergency medical attention from R1’s initial injury resulting in an approximate two hour time gap between initial injury and arrival of Emergency Medical System (EMS). R1 was transported to the ER and received medical attention and five stiches to laceration.

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 8), is being cited on the attached LIC 9099D. Appeal Rights Given

Executive Director or Administrator will be sending R1's Hospital ER Discharge documents from hospital visit of 10/15/2022 by EOB 12/30/2022.

The licensee was informed that civil penalties are under review by the Department per Health and Safety Code 1569.49 (f).

The Regional Office will be conducting an informal meeting to discuss concerns identified by the Department.