Complaint Investigation Report

A review of C1’s records revealed that C1 had been diagnosed with mild intellectual disability and cerebral palsy. C1 also had a special health condition involving seizures, which resulted in weakness and slowed movement. Records indicated that C1 experiences petit mal seizures and pseudo-seizures that cause body tremors.

During an interview, C1 stated that S1 pulled their arm hard and that the arm remained sore. On May 1, 2025, during a facility visit, C1 reiterated that S1 pulled their arm and again stated the arm was still sore.

S1, during an interview, admitted to raising C1’s arm while assisting with dressing. S1 denied intent to cause harm and said they were simply helping. Staff interviews revealed that S1 was a new employee, still in the process of completing required training and shadowing more experienced staff. The Administrator confirmed that on the day of the incident, S1 was assisting C1 without supervision.

There were no witnesses to the incident. During interviews, C1 reported that they generally feel respected by staff and enjoy living at the facility, stating this was the only instance where they felt rushed to get ready for their day program.

Interviews with other staff and clients indicated this was an isolated incident and not consistent with standard protocol. Staff emphasized the importance of adhering to C1’s care plan, which stated that C1 must be treated gently and given sufficient time during dressing and hygiene routines to prevent injury.

Based on the investigation, the Department determined that sufficient evidence exists to substantiate the allegation. A substantiated finding indicates that the allegation is valid because the preponderance of evidence standard has been met.

A deficiency was cited in accordance with Title 22, Division 6, Chapter 8 of the California Code of Regulations, as documented on LIC 9099-D. A Plan of Correction (POC) was developed in collaboration with Administrator Grace Cosico.

An exit interview was conducted with Administrator Cosico and Staff Nelson Baul. A copy of this report and the Licensee Appeal Rights (LIC 9058 03/22) were provided at the conclusion of the visit.