Complaint Investigation Report

On 02/21/2025, it was reported that Client 1 (C1) was picked up early at 11:30 a.m. due to having a terrible cough. When C1 got picked up, their family member realized they needed changing and went back inside to change the client. DP's Supervisor assisted in changing C1. Family member mentioned to Supervisor that C1's skin is easily irritated and both of them observed a small irritated spot on C1. C1's Staff (S1) for that day was informed C1 needed to be changed, and S1 apologized for their oversight.

On 02/26/25, LPA Cortez conducted a case management visit regarding the self reported incident. During the visit the LPA conducted (2) staff interviews and a file review. Interview with the DP's supervisor revealed that S1 was not a regular staff, did not read C1's file and therefore was not aware that C1 needed to be changed as part of their care needs. Furthermore, C1 went from 8:30 a.m. to 11:30 a.m. on 02/21/25 without being changed. File review conducted on 2/26/25, revealed that C1 needs to be toileted when they get to the DP, after lunch and before they get on the bus and that they have very sensitive skin and will break out in a rash if they are not changed properly.

During today's visit the DP's Supervisor revealed that only they and C1's family member where in the changing room changing C1 on 02/21/25, they did not observed any bleeding but C1 was absolutely irritated. Based on the information obtained, the Department has sufficient evidence to support the allegation, therefore the allegation Staff did not meet the needs of a client while in care , is Substantiated at this time.

Per the California Code of Regulations, Title 22, deficiency was cited during prior case management visit conducted on 02/26/2025 regarding same incident . Another deficiency will not be issued at this time. Exit interview conducted. A copy of the report was provided.