Complaint Investigation Report

Allegation #1: Staff did not take residents to scheduled medical appointments.

The complaint alleged that the client missed a podiatry appointment on September 11, 2024. On April 9, 2026, the department interviewed the Administrator (A1), who denied the allegation. A1 explained that on the day of the appointment, the client exhibited aggressive behavior, verbally abused staff, and refused to get into the car. The facility made efforts to de-escalate the situation. During this time, the podiatrist called about the appointment, and we explained that we needed to reschedule because the client's behavior prevented us from taking C1. A1 also noted that the client has transportation issues and had been expelled from the day program due to safety concerns during vehicle travel. Additionally, A1 stated that the facility took the client to the rescheduled appointment on September 12, 2024.

On the same day, the department interviewed one staff member (S1), who confirmed that the client (C1) is very aggressive, has hit staff, and does not remain seated in the vehicle with the seat belt on. The department also interviewed three other clients (C2-C4), all of whom stated that they enjoy living at the facility and that the staff takes them to all their appointments.

On April 9, 2026, the department reviewed the consent form for surgery dated September 12, 2024, which confirmed that the facility had rescheduled the client's appointment for the following day. The department also reviewed the Whole Person Assessment (WPA), which confirmed that C1 missed the appointment due to aggressive behavior toward staff. The department received a copy of the Unusual Incident Report submitted by the facility to the Community Care Licensing Department (CCLD) on September 11, 2024, regarding the incident that day. The department also received a copy of the recommendation from the Behavior consultant dated 09/13/24, which limited the client's outing due to behavior while traveling in a vehicle.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur; therefore, the Allegation is Unsubstantiated.

An exit interview conducted. A copy of the report was provided to the Administrator, Jacqueline Sanchez.