Complaint Investigation Report

306005901-9-7-2023-22-AS-SSAS-CVWQLJ-20230922121602

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 770 THE CITY DR., SUITE 7100

This is an official report of an unannounced visit/investigation of a complaint received in our office on

04/04/2023 and conducted by Evaluator Jerome Haley

COMPLAINT CONTROL NUMBER: 22-AS-20230404094217

Staff do not prevent residents from abusing other residents in care.

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to Amend the report on the complaint allegation above. LPA Haley was granted entry and explained the reason for the visit with staff.

LPA Haley conducted follow up interviews with witnesses after the original report was provided July 3, 2023. Some of the witnesses who were originally interviewed were not able to be reached for a follow up interview.

Regarding the allegation above, during witness interviews it was discovered Resident 2 (R2) was abusive to other residents and staff. 6 of 7 witnesses provided information that confirm Resident 2 (R2) was abusive and displayed aggressive behavior. Document review support the information obtained during witness interviews and reveal R2 had aggressive episodes with residents and caregivers. It was documented on March 10, 2023, R2 hit a resident with his fist and attempted to hit a resident with a walker. On March 12, 2023, it was documented R2 was physically aggressive with other residents, and on March 13, 2023, it was documented R2 entered another resident’s room and made the resident cry.

Follow up interviews revealed there was no specific plan or directions given to staff to address R2’s behavior. On the morning of March 14, 2023, R2 had two behavior incidents before being sent to the hospital and being placed on a psych hold. R2 never returned to the community after being sent to the hospital.

Based on the evidence gathered through interviews, and document review the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6, Chapter 1.

An exit interview was conducted and a copy of this report and appeal rights were provided.