Complaint Investigation Report

S1 stated that, upon reflection, they exercised poor judgment in using this method. S1 further stated that they used this method on one other occasion with R1 but could not recall the exact date. S1 reported that they did not use this method with any other residents in care and they did not inform their direct supervisor or management. Interviews and record reviews further revealed that Staff #2 (S2) was aware that S1 was using ketchup with R1 for this purpose.

LPA's interview with Executive Director stated they had spoken with R1's family member/responsible party, who reported being aware that staff were using this method because R1 had previously refused multiple attempts by staff to assist with changing clothes. According to the Executive Director , the family member/responsible party stated they did not believe staff had malicious intent and had previously discussed the method with staff.

Executive Director further stated they were not aware of any prior discussions between S1 and the family member/responsible party regarding the use of ketchup. In addition, the Executive Director informed the family member/responsible party that alternative redirection and intervention techniques could have been utilized instead of intentionally soiling R1's clothing.

LPA interviewed three staff members who regularly work in the area where R1 resides. These staff members stated they had not observed other residents being intentionally soiled with food or otherwise treated in an inappropriate manner. Based on the information obtained during the investigation, the allegation of "Staff are mistreating a resident in care" has been substantiated at this time.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D.) Executive Director was informed that failure to correct the deficiency may result in civil penalties.

Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided