Complaint Investigation Report

appetite; and emotional distress related to recent fires affecting relatives. Staff reported they observed behavioral concerns but no physical symptoms indicating a medical emergency.

AD Sharma contacted C1’s psychiatrist and obtained an in-person appointment on January 29, 2025 after observing C1’s behavioral changes. Psychiatric records documented behavioral abnormalities and included a recommendation for C1 to follow up with their primary care physician (PCP). The psychiatrist stated that the condition observed at the time did not require emergency medical attention.

AD Sharma later provided text messages between themselves and a Direct Support Professional (DSP) indicating that on January 31, 2025, C1’s PCP was contacted and the earliest available appointment was made for February 14, 2025. Although the PCP reported having no record of this contact, the conflicting information could not be resolved.

On February 1, 2025, C1 went on a family outing. Upon picking C1 up, C1’s family reported C1 could barely walk and not themselves. C1’s family reported wanting to take C1 to the hospital but did not at the urging of C1. External facility camera’s observed on site were reported by AD Sharma not to be working. On February 2, 2025, the family transported C1 to Anaheim Global Medical Center due to worsening symptoms. Hospital records showed diagnoses including urinary tract infection, acute kidney injury, dehydration, elevated lithium levels, hyperglycemia, and hypercalcemia. A review of C1’s physician report did not reveal a known diagnosis of diabetes. C1 was hospitalized from February 2–20, 2025.

Other clients interviewed stated that the facility consistently provides medical assistance and transportation to medical appointments. No client expressed concerns regarding delays in medical care.

It was alleged that staff did not meet the needs and care of the client. Interviews and records reviewed show that the facility provided meals, supervision, and behavioral support consistent with C1’s needs prior to hospitalization. C1’s Individual Program Plan (IPP) did not document any known diabetic conditions or special diet requirements. Per observations of the facility’s food supply, an adequate supply and nutritious options were observed available. Staff reported encouraging C1 to eat balanced meals.

(Complaint Investigation continued on LIC9099C)