Complaint Investigation Report

On April 10, 2024, the Department received an incident report from the facility which stated the following: On March 28, 2024, staff alerted the ADM around 7:15pm due to R1’s labored breathing. Staff were concerned that R1 might need urgent care or medical attention due to his/her difficult breathing. ADM called R1’s conservator but he/she did not answer. Staff were instructed to call paramedics if they are concerned about R1’s breathing. Paramedics arrived and but could not get in touch with R1’s conservator. Paramedics took R1 and staff are not allowed to ride with individual in ambulance. R1’s conservator dropped R1 off at the care home just after midnight.

On April 17, 2024, LPA Manuel Monter interviewed Witness 1 (W1). W1 stated he/she was contacted by the hospital and was informed that R1 was at the hospital alone. W1 stated when he/she arrived at the hospital, he/she did not observe any staff or the facility Administrator with R1. W1 stated he/she stayed with R1 while until they finished their tests and returned R1 to the care home after midnight.

On April 17, 2024, LPA's Dolores and Monter interviewed ADM. ADM stated she did everything she could do to communicate with R1's conservator. ADM stated that the emergency room was not a good setting for R1 due to his/her behaviors. ADM stated staff did not go with R1 to the hospital.

Based on a review of R1, Individual Program Plan, dated September 16, 2022, R1 requires constant supervision during waking hours to prevent injury/harm in all settings.

Based on interviews and evidenced reviewed the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED .

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.

This report was reviewed with Administrator Kaitlyn Brownell and a copy of the report was provided. Appeal Rights was provided.