Complaint Investigation Report

The LIC624 Unusual Incident Report (IR) submitted to the Department on 09/13/2020 states that on 09/13/2020, staff S1 observed resident R1 on the ground on top of R2 and pinning R2 to the ground.

The IR states that the immediate action S1 took was to call 911.

The IR does not state what the facility action plan was to ensure that R1 and R2 did not cause any harm to one another after each of them returned to the facility.

R1’s Medication Log states R1 was living in the Palms House R2’s Medication Log states that R2 was living in the Main House during the time of the incident reporting in the IR.

S2 stated to not be able to find any action plan about how staff would ensure that R1 and R2 were not involved in another altercation with each other.

R4’s Physician’s Report states R4 is able to leave the facility unassisted.

A Police Report dated 09/06/2020 states that S1 reported to police on 09/05/2020 that R4 had left the facility without permission and had not returned by 11PM curfew. The Police Report states that Emergency Psychiatric Services (EPS) had found R4 on 09/14/2020 at 9:50 PM.

R4’s Medication Administration Record (MAR) states that on 09/05/2020 R4 took morning medications and was absent for the evening medications.

On 08/15/2023, LPA Marrufo interviewed staff S2, who stated to not be able to find any earlier Daily Logs on R4’s absence from the facility or any LIC624 Unusual Incident Report.

Based on information from interviews conducted with staff and residents, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22. This report was reviewed with Brian Castenada and a copy of this report was provided. Page 2 of 2. END REPORT.