Complaint Investigation Report

The second resident suffered a small cut, refused the hospital, and received first aid at the facility. The third resident suffered a headache but refused the hospital. The fourth resident was not injured. AD also reported that on 05/04/21 R1 punched a staff member in the jaw resulting in jaw pain and that on 08/30/21 R1 was in an altercation with a resident which resulted in scratches to both residents. In response to these incidents, the facility attempted verbal redirection of R1 and obtaining a new medical assessment, which R1 refused. However, these measures have not been effective, and thus the facility has not protected residents from harm. In addition, interviews with AD and review of documents revealed that the facility did not reappraise R1’s care needs for two (2) years despite R1’s change of condition and increased aggression which began in late 2019, and in any event was not providing adequate care and supervision to R1 as evidenced by R1’s attacks on other residents and the injuries R1 also sustained in some altercations. Thus, the allegation that a resident has caused harm to other residents while in care is substantiated.

During the course of the investigation, CCLD obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Facility representative via tele-visit. This report will be emailed and an electronic email read receipt confirms receipt of the report. Facility representative agrees to send a signed copy by email.