Complaint Investigation Report

C1 LIC(625) Appraisal Needs and Service Plan states that C1 is monitored for physical aggression (Hit, grab, throw objects), disruptive behavior (Property destruction, loud vocalization, and grabbing food). Body checks are checks are done during pick up and drop off. LPA Lund reviewed C1’s Mission Bay Works Adult Day Program Body Check Forms dated July 3, 2023, through July 31, 2023, states that C1 did not have any marks when C1 arrived on July 6, 2023. The facility was not able to do a body check when C1 left the facility on July 6, 2023, due to C1’s incident and dad coming to pick up C1.

Based on facility records reviewed, interviews with staff, reporting party, witnesses and clients in care on the information provided, it was unclear if staff is unable to manage resident’s behavior resulted in property destruction and self-injurious behavior, therefore the allegation was deemed UNSUBSTANTIATED.

Staff physically hit a resident which resulted in bruising- LPA Lund reviewed facility records, interviewed staff, and residents in care. Based on facility records review, interviews with staff, and clients in care. On July 6, 2023, Client (C1) started screaming, crying, throwing himself against plexiglas glass and couch. C1 also was hitting self in the face and neck. Staff and lead staff redirected C1 to the quite room. C1’s father came to pick up C1 and was noted that C1 was still agitated and not have calmed down when leaving. The day program turned in a Special Incident Report dated July 7, 2023, for the incident on July 6, 2023. LPA reviewed Abuse, Neglect, and Exploitation in the Elder Care Setting for management and Abuse and Neglect for staff. Staff interviewed stated “That they have never witnessed any staff hit any clients in care”. Clients interviewed stated “They have never been hit or seen any clients in care been hit”.

Based on facility records review, interviews with staff, and clients in care on the information provided, it was unclear if staff physically hit a resident which resulted in bruising, therefore the allegation was deemed UNSUBSTANTIATED.

As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and report left.