Complaint Investigation Report

According to their latest LIC602 Physician’s Report, C1 was diagnosed with Mild Intellectual Disability and Schizophrenia, and their doctor determined that C1 required staff assistance to safely store and take their medications. Per facility and SDRC care records and staff interviews, C1 did not have any recent problems with aggressive or self-injurious behaviors. LPA observed that C1 was alert, aware, and oriented, and able to be qualified as a witness for this case.

SDRC records, and staff and outside source interviews, closely aligned to show: On the afternoon of 11-27-2024, Staff #1 (S1) was supposed to be at the facility to receive C1 as they came home from their day program. However, S1 had earlier left to run an errand, and they did not make it back to the facility on time. S1 did not notify Licensee that they were running late. C1 was dropped off at the facility by the day program transportation, and C1 then entered the facility using a coded-entry access via the garage. C1 was indeed at the facility without any facility staff present; the period in question did not exceed 30 minutes. [The other two clients of the facility, Client #2 (C2) and Client #3 (C3), were still at their respective day programs during this incident and were not affected by it.]

During this time, S1’s set of facility keys were left atop of a cabinet about five feet in height (which C1 was tall enough to see and reach). During today’s visit, LPA observation, confirmed by staff interviews, showed the keys in question corresponded to cabinets at the facility, which contained, in part: Confidential records for 3 of 3 clients, medications for 3 of 3 clients, and other medications pending destruction. During the incident, these cabinets themselves were locked, but S1 keys to said locks were unsecured. Also, earlier around 7:00 AM on 11-27-2024, S1 had prepared a food dish containing chicken and pork. S1 left this dish in a pan atop a stovetop which was turned off, for around seven (7) hours, instead of storing it in the refrigerator.

Per interview of C1, during the time they were alone at the facility: No harm or injury befell C1. C1 could have accessed S1’s keys, but they did not pay attention to C1’s keys nor attempt to open any of the cabinets in question. C1 could have accessed the food in question, but they did not try to eat it. (Said food was not served to clients).