Complaint Investigation Report

During today’s visit, LPA reviewed the following documents. Resident Roster (dated 03/10/22), Staff Roster & DSP Work Schedules (dated 11/12/21), Client #1 Face Sheet (dated 01/18/18), ID/Emergency Info (dated 03/10/22), Individual Personal Plans (period 04/20/22), Medication Administration Records (dated August 2022), Admissions Agreements (dated 01/18/22), Behavioral Support Plans, Physicians Reports (dated 03/10/22), Incident Report (dated 08/09/22), Body Check – Clinical Chart (dated 08/08/22 and 08/09/22), Redirection Tracking Sheet (dated 09/05/22 thru 09/11/22); Administrator and Staff training records (05/04/21 thru 04/04/22). Harbor Regional Center (HRC) Incident Report (dated 08/10/22). Long Beach Fire Dept (LBFD) Incident Report, Ambulance Transport Services report (dated 08/09/22), and Patient Release form (dated 08/09/22). Long Beach Police Dept (LBPD) Incident Report (dated 08/09/22).

The complaint was referred to the California Department of Social Services Investigations Branch and was assigned to investigator (Heidy Bendana) which included a review of medical records (dated 08/09/22); interviews of medical services personnel (Witness #3 - #6); local law enforcement (W#1, W#2, W#10); Harbor Regional Center staff (W#7, W#9); Facility Staff #A2, #S1, #S2, #S3, #S4, #S6; and Clients #1, #2.

Regarding Allegation #1 : This investigation revealed that Client #1 sustained multiple injuries based on medical records from St. Mary Medical Center (dated 08/09/22), Long Beach Fire Dept Incident Report (dated 08/09/22), and Long Beach Police Dept Report DR# 22-39040 (dated 08/09/22). Reports notated that Client #1’s injuries were consistent with physical abuse and the injury patterns matched the object (potato smasher) patterns that was collected (in the facility’s kitchen) as evidence. These marks caused Client #1’s skin to turn a reddish color and were observed on the client’s back, below the right armpit, left bicep area, left buttocks, inner thighs, left shoulder blade - adjacent to the right armpit, and lower left leg - near the thigh area (photographs). Client #1 was discharged from the hospital on 08/10/22 with a diagnosis of hematoma due to physical abuse; and it was documented that the injury patterns matched the object (potato smasher) patterns used in the physical abuse.