Complaint Investigation Report

During interviews facility staff admitted that C1 has fallen a total of three times in the last six months beginning January 2022 and none of these instances were witnessed by staff. C2 stated they did not see C1 fall but heard a “thud” and observed C1 bleeding on the right side of their head. C2 then alerted staff, who took “about 5 minutes to go check” on C1. LPA reviewed the Needs and Services Plan (LIC625) for C1 dated 3/02/2022, which states the facility “feels” C1 needs more supervision and a higher level of care. The facility, however, did not provide C1 with more supervision or assistance in obtaining a higher level of care. Per disclosures made during interviews, and records obtained by LPA, it was determined that facility lacks care and supervision and facility is unable to meet client’s needs resulting in multiple falls. The preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated California Code of Regulations, Title 22, 85075.4(b) and 85078(a)(1).

An exit interview was conducted. A copy of this report, and appeal rights were left at the facility.