Complaint Investigation Report

LPA reviewed C1’s Individual Program Plan, which notes that C1 requires constant supervision during waking hours to prevent injury/harm in all settings/situations as C1 does not possess or exercise appropriate safety awareness. LPA reviewed the facility's program statement which notes the staffing schedule at People’s Care Temecula Community Program is based on a 1:3 ratio.

Regarding the allegation, “Staff did not ensure care and supervision was provided to the client”, LPA interviewed S1 who reported they were in the art room with their three (3) assigned clients when they witnessed S2 relieve Staff 3 (S3) from their duties of supervising C1. S1 reported they were in the art room with S2 and C1 when they witnessed S2 leave the room, leaving C1 unsupervised. LPA interviewed S2 who confirmed supervising C1 on 1/8/2024 after S3 left early. S2 reported only assisting C1 with incontinence needs and getting into the transportation van, and listed Staff 4 (S4) as a possible witness. LPA was unable to corroborate the information provided by S2. S2 denied being in the art room with C1; however, interviews revealed S2 was observed with C1 in the art room and walking around the facility after S3 left early on 1/8/2024. Based on interviews conducted, this allegation is Substantiated.

Regarding the allegation, “Client sustained injury while in care”, S1 reported that after S2 left C1 unsupervised, S1 witnessed C1 stand up on their own from their wheelchair and fall back. S1 reported they ran to assist C1 up and observed C1 sustained a scratch and redness on their back from the fall. C1’s board and care facility reported they conduct client body checks before clients leave to day program and upon arrival from day program. LPA reviewed C1’s board and care facility’s Body Check Logs (BCLs). The BCL for C1 dated 1/8/2024 at 7:00 a.m. did not state observation of a bruise/scratch. The BCL dated 1/8/2024, at 5:00 p.m., notes that C1 was observed to have a scratch. The BLC dated the following day, 1/9/2024 at 7:00 a.m., notes observation of a bruise on the scratch. LPA also reviewed a photograph of the scratch and bruise observed on C1 upon arriving from day program on 1/8/2024. Based on interviews conducted and record review, this allegation is Substantiated.

An exit interview was conducted and this report was reviewed and provided to Administrator Williams along with a Confidential Names List (LIC811), LIC9099-D, and Appeal Rights.