Complaint Investigation Report

547203972-5-8-2024-24-AS-SPIY-D5ALZC-20240515091140

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

This is an official report of an unannounced visit/investigation of a complaint received in our office on

02/05/2024 and conducted by Evaluator Katie Brown

COMPLAINT CONTROL NUMBER: 24-AS-20240205160913

Staff did not provide adequate supervision resulting in resident sustaining a fracture due to a fall

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to deliver investigation findings. LPA met with and explained the reason for the visit with Program Director (PD) Maria Lowes

Interviews reveal that Client (C1) has a history of falls and unsteady gait while ambulating at home and Day Program (DP). C1 fell at DP on 1/29/24. According to the 2 staff present at the time of the fall, C1 got up independently and did not verbalize pain or limping. C2 stated C1 fell that day at DP and at home. C1 was taken to urgent care on 1/30/24 and diagnosed with a fracture. It cannot be determined that the fracture occurred at the day program. Based on interview and record review the above allegations are UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur.

There were no citations issued. An exit interview was conducted and a copy of this report was left with PD, whose signature confirms receipt of this report.