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32 | (Continued from LIC 9099)
LPA interviewed four of four staff; including S1, the staff member directly involved, who all denied the allegations. LPA spoke with two clients, one involved in the incident, who is non-verbal, and the other, a verbal client. The verbal client stated the staff member does not yell at them and has never tried to hit residents. LPA engaged with the non-verbal client who smiled at LPA. LPA observed client to be oriented to time and place and used body language, such as hand gestures and nodding. Client understands questions asked by LPA and staff. When asked about staff member, S1, LPA observed the client to be relaxed, nodding head up and down and smiling.
Documents obtained and reviewed include the Client’s: Identification and Emergency Information, Physician’s Report and Appraisal/ Needs and Services Plan. Additional documents obtained include the Register of Facility Clients and the facility sign-in/sign-out sheet; signed by the vendor on the day of the incident. Upon file review client is prone to have aggressive incidents per Individual Program Plan (IPP) dated February 24, 2024. LPA reviewed Staff #1’s file and there were no disciplinary actions on record. S1's staff training included Elder Abuse and mandated reporting from July 7, 2024.
Two staff members were interviewed from the Day Program, who reported the allegations. The eyewitness stated the yelling, by S1, was not shouting, but a raised voice. The eyewitness stated S1 moved her hand from side-to-side, as if to swat the client’s hands. Eyewitness stated staff member raised her hand to client’s face and, again, moved her hand from side-to-side. No contact was made. Eyewitness stated S1 spoke to client, “Like a parent addressing a toddler” which witness felt was not professional.
LPA spoke with the Regional Center of Orange County (RCOC) Quality Assurance Coordinator (QAC), who had also visited the facility on February 11, 2025. The RCOC QAC’s findings were inconclusive.
A 9102-TV has been issued to request staff training on recognizing and mitigating client behaviors, as well as documenting behavioral incidents in client’s file.
Although the above allegations may have happened there is not a preponderance of evidence to prove the alleged violations occurred; therefore, the allegations that: staff yelled at client and that staff attempted to hit client is unsubstantiated.
An exit interview was conducted with Melissa Carbajal and Mindy Fajardo, Administrators, and a copy of this report and LIC 9102-TV was provided to the facility.
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