Complaint Investigation Report

Regarding “Staff did not prevent client from sustaining a sunburn while on an outing” LPAs obtained information through interviews that some residents used the sunscreen spray on themselves at day program, others stated they used sunscreen prior to arriving to the day program and others did not use it at all. The investigation revealed that residents R1, R8, R11, S5, R12, S2 all had sun burns although some may have reapplied sunscreen during the day. No staff urged residents to take a break in the shade. Some residents were without direct staff supervision. S2 also stated that everyone got a little sunburned but medical attention was not necessary except for R1. R1s information was revealed during a meeting. LPAs observed that R1-R6 reside in a residential facility, while R7-R12 are independent and reside with family. LPAs observed through interviews that the facility staff offered sunscreen before and during the trip. However, staff did not make sufficient attempts to guide residents to reapply sunblock, suggest or provide head coverings or redirect residents to shaded areas.

Regarding “Staff did not properly supervise clients while on an outing” LPAs conducted interviews of 9 of 12 residents and S1-S5. The investigation revealed that the facility and a sister facility joined in the outing. During the outing, residents were allowed to choose their groups to spend the day with. All the groups were to meet back at the chosen area to have lunch. There was a group of 4 residents of which 2 were not able to leave unassisted per the physician report (LIC602). This group did not have staff with them as they traveled around the amusement park. Another 2 residents of which 1 is not able to leave unassisted was using the buddy system, did not have staff present. The Physician report states that residents are not to leave unassisted, they all were accompanied by a person(s) who did not need assistance but residents are not to serve as staff. Residents that cannot leave unassisted, must be accompanied by staff.

Civil Penalties will be issued be issued on 10/25/23. See Form LIC421IM.

Based on interviews with staff and the administrator confirming that allegations were true, the preponderance of evidence standard has been met. Therefore the above allegations are found to be SUBSTANTIATED. per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 6, deficiencies are being cited on the attached LIC-9099D. Appeal rights were provided. An exit interview was conducted, and a copy of the report was provided.

Civil Penalties will be issued be issued on 10/25/23.