happened. In addition on 12/14/21, C1 was taken to dentist appointment and C1 was observed with swollen left calf.

-Regarding allegation: Client sustained unexplained injuries while in care. During record review LPA reviewed Unusual Incident Report (UIR) from Coellos Residential Care; It was reported that on 12/09/21 Client #1's front tooth had split in half – vertically, unknown how injury happened. Per IPP Dated: 10/07/2020 C1 is diagnosed with profound intellectual disability, psychosis, and Impulse control disorder. Goals include reducing instances of injuring self, being physically aggressive, removing clothes, spitting, smearing saliva, and emotional outbursts. C1s team assist in redirecting, trying to de-escalate, and prevent these occurrences. Emotional outbursts include screaming, yelling, jumping, falling on the ground and or/ tearing paper or breaking items. C1 exhibits self injurious behaviors like slapping/ hitting self, picking at face, fingers, chest, and stomach, as well as scratching or biting lips. The Coello team will praise C1 for appropriate behavior, maintain a predictable schedule and notify of changes to prevent situations. Per IPP dated 09/07/2016 C1 is able to ambulate independently, although client is noted to trip and walk into objects frequently because client is not looking where they are going and drags feet when walking. Per record from Encouraging Personal Independence (EPI) adult Day program Individual Service Plan dated 08/10/21 C1 exhibits Inappropriate physical interactions with others, reckless ambulation, unsteady gait, lack of awareness of physical environment, self injurious behavior (ie picking at face/ hitting self), cognitive impairment.

On 12/21/22 LPA Cardenas interviewed RP who states that reporting was obtained indicating that on 12/09/21 C1s mouth was bleeding, had swelling around nose area, and had a swollen right foot. Administrator was unable to explain how the injury happened. C1s behaviors is to throw self onto the floor. Falling is a behaviors under tantrum like behavior. In addition, other behaviors include emotional outburst of screaming, falling, exhibiting self injurious behaviors. RP states Antecedent to behaviors is when C1 is asked to terminate one activity or change behaviors. Facility has plan in place to minimize behaviors, however behaviors can be sporadic. RP reached out to C1s doctor who noted that during an office appointment Dr has observed C1 throwing thyself on the hallways.

On 12/21/21 LPA Cardenas interviewed Staff#1 who was present during the incident on 12/09/21; S1 states C1 was at the table; sitting down and ready for lunch. S1 brought client a plate and noticed bleeding coming from client’s mouth. S1 states that during this time she didn’t hear any noises that would indicate a fall, any

hitting, throwing, etc. All the clients were engaged in their own activities. C1s behavior is throwing self to the floor sporadically with no warning. During interview with S2, staff indicates that on 12/09/21 she clocked out at 9am and wasn’t on shift when C1 split tooth. That morning S2 assisted client with brushing teeth and nothing odd was observed. C1 tends to fall and throw self on the floor for no reason. S2 has not witnessed staff nor clients physically hit other clients. During interview with administrator, Bessie Coello; Bessie states that S1 observed that C1 was bleeding from mouth and a piece of tooth was missing. C1 falls on floor at times. when staff observe that client will throw self, staff will stop trying to redirect to avoid falls. On 12/21/21 LPA Cardenas attempted to interview four (4) clients however LPA was unable to obtain statement due to developmental disability. LPA observed four (4) clients in the Livingroom engaged in their own independent activity. On 6/17/22 LPA interviewed S3 who also confirmed client has self injurious behaviors, picks at skin and throws self to the floor sporadically. S3 was not present during the incident on 12/9/21; clients are taken well care of.

Based on LPA’s interviews and record reviews, LPA did not find sufficient evidence to support the allegation, Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED.

An exit interview was conducted. A copy of the report to be provided to administrator, Bessie Coello.