NARRATIVE |
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32 | During the course of this investigation: Investigator Santana received a copy of Pomona Police Department Records Division Incident Report #22-050618 on 10/06/22. On 10/18/22, Mr. Santana reviewed documents obtained by LPA Gonzalez during Initial 10-Day Visit conducted on 10/5/22. On 10/12/22, Investigator Santana interviewed C1, Staff 1- 2 (S1-2). On 10/13/22, Mr. Santana interviewed San Gabriel/ Pomona Regional Center Service Coordinator (SGPRC SC) Nicole Anderson by phone. On 10/20/22, Investigator Santana reviewed C1’s Pomona Valley Hospital Medical Center Hospital Records. On 10/21/22, Mr. Santana visited the facility and interviewed S3 - 4 and collected copies of C1’s Consumer Notes and Body Check Diagram. On 10/25/22, S3 texted Investigator Santana copies of pictures S3 took of C1’s injury and C1’s Client Notes dated 05/16/22. On 10/28/22, Investigator Santana interviewed Administrator Junelle Canones. On 11/01/22, Pomona Police Department Detective Christopher Blank was interviewed by telephone. On 11/3/22, Investigator Santana reviewed S5’s Death Certificate. On 11/15/23, Investigator requested a copy of follow-up incident report #22-050618 from Pomona Police Department Records Division which was not received. On 1/12/23, Investigator Santana received a copy of supplemental Incident Report #22-050618 from Pomona Police Department Records Division.
The investigation revealed the following: Regarding allegation of Staff caused fracture injury to resident, it is alleged that a facility staff (S5) pushed C1 resulting in a fractured left hand. Investigator Santana conducted interviews with facility staff, facility client, SGPRC SC Nicole Anderson and reviewed documents pertinent to the investigation. S5 was not interviewed as they passed away on 06/05/22. The investigation revealed that although there were no witnesses to the actual incident that resulted in C1’s hand fracture, S4 heard the verbal altercation between C1 and S5 in the living room from the dining room and then heard C1’s body hit the floor. S4 stated that S5 admitted to pushing C1 because C1 attempted to strike S5 after their verbal altercation. Facility Administrator stated that facility staff are trained in Crisis Prevention Intervention (CPI) to address clients’ aggressive behaviors and stated that the proper response to C1’s escalated behavior would have been for S5 to create space between C1 and S5 and call another facility staff.
Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6, and Chapter 1 are being cited.
(See LIC 9099C for continuation of report) |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
10/04/2023
Section Cited
CCR
80072(a)(1) | 1
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7 | 80072(a)(1) - Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. | 1
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7 | Licensee shall develop a written Plan of Correction to ensure compliance with California Code of Regulations Title 22, Section 80072(a)(1). Written POC must be submitted to CCL by the POC due date. |
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14 | This requirement was not met as evidenced by: Based on IB Investigator Santana’s interviews with staff who stated that S5 was involved in a verbal altercation which turned physical with C1 which resulted in C1 sustaining a fracture injury on their left hand. This poses an immediate safety and personal rights risk to clients in care.
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Type A
10/04/2023
Section Cited
CCR
80072(a)(3) | 1
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7 | 80072(a)(3) - Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. | 1
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7 | Licensee shall develop a written Plan of Correction to ensure compliance with California Code of Regulations Title 22, Section 80072(a)(3). Written POC must be submitted to CCL by the POC due date. |
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14 | This requirement was not met as evidenced by: Based on IB Investigator Santana’s interviews with staff who stated that S5 was involved in a verbal altercation which turned physical with C1 which resulted in C1 sustaining a fracture injury on their left hand. This poses an immediate safety and personal rights risk to clients in care.
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14 | **Immediate Civil Penalties will be assessed in the amount of $500.00. ** |