Complaint Investigation Report

Interviews conducted of Staff (S1, S4) on 04/04/24 corroborated that the facility maintains Caregiver Notes (dated 02/20/22 – 02/24/22) regarding clients’ incidents; and they will report it to the House Manager who reports it to the Administrator. Facility staff replied that they did not receive a complaint from Client #1’s Conservator/Responsible Person on or about 02/20/22 – 02/25/22 regarding staff not communicating to Client #1’s authorized representative. Facility staff confirmed that they are aware of being a Mandated Reporter and receive in-service training on an annual basis. Facility staff also confirmed having received Mandated Reporter training upon hire. [A review of facility staff In-Service Training Sign-in Sheet on the topic of Mandated Reporting was dated MM/DD/YY.] Administrator #3 (A3: Mary Cruz) confirmed that the House Managers will report serious incidents if it cannot be handled at the lower level. LPA/RA Ceniceros conducted virtual interviews on 04/04/22 with Clients (C2, C3, C4, C9) who corroborated that they have not had concerns with the facility not reporting an incident that involved them or not communicating an incident to their conservator/responsible person; however, the majority are their own responsible person. [Facility staff In-Service Training Sign-in Sheet on the topic of Reporting Requirements was dated MM/DD/YY, Unusual Incident/Injury Report (dated 02/22/22), staff work schedules & roster (February 2022), clients’ roster (February 2022), and Client #1’s Emergency Identification Information/Face Sheet (dated 01/01/22) were reviewed.

Regarding Allegation #2 : this investigation revealed that the facility failed to notify reporting agency (CCLD) and appropriate parties (Conservator/Responsible Person) regarding an incident that occurred on 02/20/22 involving Client #1’s hospitalization - including an update [based on the “Unusual Injury/Incident Report” (dated 02/22/22)] regarding Client #1’s hospitalization status. LPA/RA Ceniceros reviewed the facility’s incident reports and observed that the facility failed to submit a LIC 624 form regarding Client #1’s incident that occurred on 02/20/22 (hospital admittance) and on 02/25/22 (hospital discharge). In addition, facility failed to submit a “ Death Report ” (dated 02/25/22) to reporting agency (CCLD) and/or document

if notification was made to appropriate parties (Conservator/Responsible Person) regarding Client #1’s passing on 02/25/22.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of PERSONAL RIGHTS: “Staff did not communicate with authorized representative” is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citations issued (ref. LIC 9099D).

An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights were provided to the Administrator (Mary Cruz).