Complaint Investigation Report

[CONTINUED FROM LIC 9099] According to C1’s LIC602 Physician’s Report (dated 05/08/2023): C1 had bipolar disorder and anxiety disorder, but they did not experience memory impairment or hallucinations. Their doctor determined that C1 was not confused, able to follow instructions, and able to communicate their needs. C1 demonstrated to LPA that they were oriented to person, place, and time and able to differentiate truth from lie. However, both internal and external interviews and care records widely showed that C1 themselves frequently chastised and/or yelled at facility staff and made false statements. These latter factors affected the weight CCLD assigned to independent testimony from C1.

Per interview of C1: During a staff shift change meeting, S1 raised their voice and spoke towards them “in a harsh way,” blaming C1’s earlier challenging behaviors for causing stress for a pregnant coworker of S1.

Per interview of S1: They admitted to recently conducting shift change meetings (with the incoming staff relieving them) in a common area of the facility where C1 overheard them. S1 said they recognized this was a mistake and they now perform shift change meetings in a private area. S1 denied raising their voice at or speaking harshly towards C1.

Per interview of Staff #2 (S2): During the complaint time period, S2 participated in a shift change meeting in which S1 spoke to them about C1’s behaviors and how they affected a coworker’s pregnancy. During the meeting, S1 was upset and raised their voice increasingly louder, wanting C1 to overhear what was being said. At one point, S1 turned towards and shook their finger at C1 to chastise them. Soon after, C1 was on the verge of tears. S2 spoke one-on-one with C1 to comfort them.

After speaking to all clients and staff of the facility, LPA did not encounter allegations or evidence of S1 or other staff raising their voice at other clients in care.

Based on interviews, a preponderance of evidence exists to show that S1 yelled at C1 (in a way that did not uphold Clients’ Personal Rights) on at least one occasion. The allegation is therefore Substantiated. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the Licensee.

An exit interview was conducted with Kareem, to whom a copy of this report, the LIC 9099-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.