Complaint Investigation Report

C1’s responsible party reported the belief that C2 required a higher level of care than the facility could provide. A review of C2’s physician’s report confirmed that C2 had a seizure disorder, required assistance with ambulation, and was unable to care for personal needs.

In an interview with the licensee, the licensee acknowledged that C2 required a higher level of care and admitted being aware that C1 had been asked to assist staff in lifting C2 from the floor. The licensee further admitted that during the incidents, S1 was the only staff on duty and was limited by a back injury. The licensee also confirmed that medical attention was not obtained at the time of C2’s falls, and instead, other clients were enlisted to assist.

Based on the preponderance of the evidence, all three allegations were substantiated. The allegation “Facility does not have sufficient staffing to assist client off the floor” was substantiated as interviews and the licensee’s statements established that only one staff member was on duty, who was unable to perform required lifting and instead relied on clients to perform staff duties. This resulted in delayed or inadequate assistance when C2 was on the floor. The allegation “Staff did not obtain medical care for the client in a timely manner” was substantiated as interviews and licensee admissions confirmed that no medical evaluation was sought following C2’s falls despite the client’s identified medical conditions and needs, thereby placing the client at potential risk of harm. The allegation “Facility not able to meet client’s needs” was substantiated as C1 and other clients were asked by S1 to lift C2 from the floor as well as C2’s physician’s report documented care requirements beyond the facility’s capabilities, and the licensee admitted retaining C2 despite knowing a higher level of care was needed.

The preponderance of evidence standard has been met; therefore, the allegations are SUBSTANTIATED. Violations are being cited under California Code of Regulations, Title 22. An exit interview was conducted, and a copy of this report along with appeal rights was provided to the licensee.