Complaint Investigation Report

An interview was conducted with Staff #1 (S1) at 10:01am. The LPA also conducted interviews with Licensee Julia Espena and Administrator Louisa Mae Cervantes during the inspection. Copies of pertinent records were obtained.

Investigator Ferris conducted interviews on 04/03/2023 with the Administrator, Staff #1 (S1), Licensees, clients, Client #1 (C1), and the reporting party; and on 05/08/2023, with the Tri-Counties Regional Center (TCRC) Service Coordinator (SC). In addition, Investigator Ferris reviewed St. John’s Regional Medical Center medical records and facility file documents related to C1 and S1.

A review of C1’s physician reports, dated 02/14/2019 and 07/27/2021, indicated C1 is diagnosed with cognitive developmental delay, chronic ataxia, able to independently transfer to and from bed, ambulatory, non-verbal, bathes, feeds, and dresses self, able to care for own toileting needs, unable to ambulate without assistance. The Individual Program Plan (IPP) dated 12/30/2022, documented C1 was attending a community-based program, is ambulatory, due to limited safety awareness and unsteady gait, must be supervised, enjoys dancing, helping roommate and making own bed. The facility Identification and Photo sheet updated 02/15/2023, lists C1 as non-verbal, diagnosis of mild mental retardation, moderate cerebral palsy, and walks with an unsteady gait.

According to the Special Incident Report (SIR) submitted by the facility, on 03/05/2023 C1 was using the restroom in between lunch, when S1 went to check on C1. As S1 entered the restroom to assist C1, C1 stood up abruptly and lost balance, falling on left hip. S1 was able to hold C1 and not hit their head on the floor. 9-1-1 was called and C1 was taken to St. John’s Regional Medical Center.

A review of the St. John’s Medical Center medical records indicated the following: C1 was admitted 03/05/2023, due to a fall at the facility. C1 slipped and fell directly on left hip. History of the present illness indicated C1 has Cerebral Palsy and mild mental retardation. X-rays revealed a left hip fracture with no reported history of prior broken bones. Surgery was performed and C1 was discharged on 03/10/2023, to a Skilled Nursing Facility (SNF) for rehabilitation and physical therapy. Investigator Ferris noted the medical records did not document any evidence or suspicion of physical abuse.