Complaint Investigation Report

LPA Phillips met with Administrator Estella Usher and explained the purpose of the visit. The LPA toured the facility and observed two (2) residents in care. The LPA requested documents pertinent to the investigation. The LPA noted further investigation was required and advised the complaint would be investigated by the Community Care Licensing (CCL) Investigations Branch (IB).

On 10/25/2023, from approximately 3:30 to 4:00pm, Investigator Zertuche conducted interviews with the reporting party, and the Tri-Counties Regional Center (TCRC) coordinator; on 10/27/2023, from approximately 10:00am 11:30am, with S1, S2, R1, other facility residents, and the Administrator; and on 11/14/2023, at approximately 10:30am, with R1’s attending physician. Additionally, Investigator Zertuche reviewed Pacific Central Coast Med Plus Orcutt medical records, Santa Maria Police Department (SMPD) report #23-0012205-001, and facility file documents, including Unusual Incident Reports (UIRs), related to R1.

A review of R1’s facility records indicated R1 is ambulatory with a diagnosis of profound intellectual disability and seizure disorder. R1 has occasional confusion and requires assistance for most daily living activities. R1 has a history of physical aggression, self-injurious behaviors, and fabricating stories. R1 can communicate using simple sentences and gestures. R1 has an unsteady gait and is assigned a 1 to 1 staff ratio. R1’s behavior support plan indicates staff should remain within arm’s reach to prevent falls.

The medical records reviewed documented R1 sustained a fractured right wrist and the notes indicated R1 has a development delay and did not know how the injury occurred. According to the report, likely causes are an accident (car, bike, etc.), sports injuries or a fall with the arm outstretched. Notes indicated that R1 disclosed to the caregiver that someone pushed them, but the incident was unwitnessed. The doctor stated there was no way of knowing for sure how R1 sustained the fracture.

According to the incident report submitted by the facility, on 09/28/2023, R1 arrived at the facility from the day program at 3:00pm. R1 informed S1 and the Administrator that a person from the day program pushed them down. When S1 checked R1, S1 observed that R1 was unable to hold their water bottle to take their meds. S1 immediately texted and called the day program to determine what happened. At 3:33pm the day program returned the call stating that “R1 did not fall at day program, R1 was unsteady, R1 was about to hit their head against the edge of a table, when staff immediately grabbed R1 so they would not get hurt”. Continued on 9099-C