Complaint Investigation Report

Interviews of outside sources and facility staff aligned to show that during the early morning of Monday 06-17-2024, multiple finger scratch marks were identified on C1’s face. The scratches were not bleeding and did not require first aid, but they looked fresh and reddened. Interviews of facility staff showed that these scratches were not present during the evening (PM) shift which ended around 10:00 PM on 06-16-2024 or the successive overnight (NOC) shift which ran from 10:00 PM on 06-16-2024 to 6:00 AM on 06-17-2024. Rather, these scratch marks were new and occurred sometime between 6:00 AM and 7:30 AM on 06-17-2024, during which time staff said C1 was by themselves either inside their private bedroom or inside the facility’s hallway bathroom.

Staff and outside source interviews aligned to show: When C1 was asked about how they got the scratches on their face, their explanations changed over time. C1 first said they scratched their face after falling into a bush. C1 later claimed that Client #2 (C2) scratched their face. By the time LPA interviewed C1 on 06-24-2024, C1’s facial scratches had fully healed, and C1 first told LPA that C2 caused the facial scratches. C1 later freely approached LPA to say they had earlier lied, and that they scratched their own face during the incident in question. [C2, meanwhile, was constant in the narrative they gave to outside sources, facility staff, and LPA; C2 consistently denied scratching C1 or having any physical altercation with them.] Multiple facility staff told LPA they suspected C1 engaged in self-scratching behavior on prior days. When LPA returned to the facility on 07-25-2024, C1 had new very light scratches on their abdomen. When LPA asked about these, C1 explained they scratched their own stomach with a Sharpie marker, and they would not tell LPA what motivated them to do it.

While Licensee’s staff did not know exactly how C1 obtained the scratches on their face (i.e., the ones discovered on 06-17-2024), the totality of evidence still did not support there being a lack of staff supervision of clients. C1’s latest LIC602 Physician’s Report, LIC9172 Functional Capability Assessment, and care documents from San Diego Regional Center (SDRC) together showed that C1 was ambulatory and largely independent in their personal care tasks. C1 needed staff reminders to shower, brush their teeth, and change their clothes, but was also physically self-capable in those areas. There was nothing to suggest that C1 needed 1-on-1 care or a level of supervision higher than what the facility normally provided.