Complaint Investigation Report

At 9:08 a.m. LPA interviewed S1. At 9:21 a.m. LPA interviewed licensee. At 9:20 a.m. LPA reviewed records.

During LPA's visit, two clients were in day program, two clients were at the facility and one client was at a skilled nursing facility.

Licensee and S1 confirmed that client 1 (C1) had passed out or had a seizure and was unconscious for several minutes on the following dates: 7/6/2023, 7/17/2023, 7/24/2023, and 8/1/2023. Emergency services were called on 7/6/2023 and C1 was taken to the hospital. However, licensee and staff failed to call emergency services or seek medical assistance on 7/17/2023, 7/24/2023, and 8/1/2023. In addition, the licensee failed to report the 7/17/2023 and 7/24/2023 incidents to Community Care Licensing (CCL) as required. Licensee will report the 8/1/2023 incident by end of business today, 8/2/2023.

Based on the above noted information, the allegations “Staff failed to seek medication attention for client in a timely manner” and “Facility failed to report incidents” are both deemed SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Exit interview conducted. A copy of the report and appeal rights were issued to the licensee.