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25 | Licensing Program Analyst (LPA), Avelina Martinez arrived on 08/16/2024 at 8:45 AM, for an unannounced Case Management visit to follow up on a substantiated allegation of complaint investigation 27-AS-20230728105712. LPA Avelina Martinez met with Marlene Bremer and Jonathan Aguila and explained the purpose of the visit.
On October 25, 2023, The Department concluded a complaint investigation which alleged the following, “Resident sustained multiple injuries while in care as a result of inadequate supervision."
The Licensee was cited for California Code of Regulations Title 22 (22 CCR) Section 67464 (f)(1) Basic Services; 87411 Personnel Requirements; and 87211 Reporting Requirements.
At the time of complaint visit on October 25, 2023, an immediate civil penalty of $500.00 was issued for Section 67464. The Licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code§ 1569.49.
The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section § 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by information gathered through interviews and facility files, that the licensee did not ensure R1 received the required care and supervision. Facility staff were aware that a resident (R2) was aggressive towards another resident (R1) but were not present when R2 physically assaulted R1. Per hospital records reviewed, R1 sustained an acute chronic intracranial subdural hematoma, a wrist fracture, and a humerus fracture.
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