Complaint Investigation Report

During the visit, LPA toured the facility, conducted interviews with staff and clients, and obtained documents pertinent to the investigation.

On the allegation: Staff inappropriately handled resident. On 11/17/2021, Resident #1 (R1) called the San Luis Obispo (SLO) Crisis team as R1 had become angry at one of the staff members at the facility. SLO Crisis Team came to the facility due to R1 was experiencing suicidal ideation while on the phone. Facility staff continued to ask R1 if they could help. R1 called S1 a derogatory name, S1 then called R1 a derogatory name. R1 then went into R1’s bedroom and punched a night stand with their hand. Staff #2 (S2) gave R1 and ice pack. The crisis team tried coming up with a safety plan for R1 and for the staff to care for R1. The crisis team told the staff that R1 was having suicidal ideations and had a plan to carry it out. S1 stated “how is R1 cutting their wrist suicidal?” The crisis team explained that R1 had a long history of suicide attempts and had marks on wrists from previous attempts. The crisis team then decided to transport R1 to Marian Medical Hospital. R1 was later released the same night back to the facility. Per the Administrator, S1 completed the suicide ideation training 11/23/2021. Based on the information obtained, the allegation staff inappropriately handled resident is substantiated at this time.

On the allegation: Staff spoke inappropriately to resident. On 12/17/2021, at 10:57am, LPA Luong attempted to contact S1 for an interview. The LPA left a voice mail but did not receive a return call. The LPA conducted interviews with Staff #2 (S2) and Staff #3 (S3) who both confirmed that they have witnessed and heard S1 speak to R1 using derogatory language calling R1 a “bitch”. Crisis Team member also confirmed they witnessed S1 calling R1 a “bitch.” Based on information obtained through interviews, the allegation staff spoke inappropriately to resident is deemed substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D).

Exit interview conducted, appeal rights discussed, and a copy of this report issued.