Complaint Investigation Report

Records indicated that on October 19, 2023, the facility reported that Client 1 (C1) had been transported to Kaiser Permanente after staff observed C1 spending an unusual and extended period in the restroom on October 18, 2023. Documentation confirmed that C1 was ambulatory and independent in personal care and hygiene, making it unlikely that staff would have observed bruising located on C1’s inner thigh prior to the transport. The facility’s prompt action to seek medical evaluation led to a diagnosis of a urinary tract infection (UTI). Based on the totality of evidence obtained from interviews and record review, the allegation that the facility failed to report the incident as a mandated reporter is deemed unsubstantiated.

The second allegation investigated was that the "Client sustained unexplained bruises on the thighs." LPA Haddadin conducted interviews with three staff members, all of whom denied the allegation, consistent with findings from the first investigation. Record review and interviews clarified that the bruising was initially discovered by Vocational Visions (VV), a separate licensed day program (Facility No. 306005250) providing one-on-one care services. The bruising was therefore observed during care provided at VV, not at the residential facility. Given C1’s independence and the absence of one-on-one assistance at the residence, facility staff were appropriately unaware of the bruising due to both the client’s high level of independence and the private nature of the affected area. Based on the evidence obtained from interviews and documentation, the allegation that "Client sustained unexplained bruises on the thighs" is also deemed unsubstantiated.

Although the above allegations may have occurred or be valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. Therefore, at this time, both allegations are determined to be unsubstantiated.

An exit interview was conducted with Administrator Randall Bates. A physical copy of this report, detailing the unsubstantiated findings for both allegations, was provided to the Administrator at the conclusion of the visit.