This Case Management - Incident visit is regarding an Incident Report (SIR) from the facility received on 04/09/2024. According to the SIR, on 04/06/2024, Staff member of the facility (S2) telephoned the facility house manager (S3) to inform them of an alleged incident that occurred 04/01/2024. According to S2 a client in care at the facility (C1) stated that a Staff member (S4) had dragged the client by their feet off their bed as they were laying down and dropped the client to the ground, which led to the client sustaining back injuries. The SIR included an attached Report of Suspected Dependent Adult/Elder Abuse (SOC 341). According to the Licensee, the facility placed S4 on leave as of 04/08/2024. According to the SIR and through interview of the facility administrator (S1) during the Case Management visit, a wellness check/body check was performed on C1 immediately after the incident occurred by C1's Licensed Marriage and Family Therapist (LMFT), Witness #1 (W1). The facility stated a plan to prevent further occurrences was to implement Staff retraining on Zero Tolerance Policy, mandated reporting, and Client Personal Rights. The Licensee stated that the facility will cooperate with any organization/regulatory agency for any required investigation and/or review. The LPA received a cross report from Adult Protective Services (APS) on 04/10/2024 that indicated an Administrator from a separate facility under the LIcensee, Staff #5 (S5), contacted APS and was planning to contact Law Enforcement. S1 stated to LPA and TCRC during this Case Management visit that Law Enforcement Officers came to the facility on 04/10/2024 to speak with C1. A copy of the report will be given to LPA and TCRC. S1 also stated an internal investigation is ongoing at this time while S4 is on leave.

During today's visit, the LPA interviewed facility client(s), Staff members, the facility Administrator, and requested/received documentation pertinent to the investigation. Continued on 809-C

This facility has several separate previous Case management incidents within less than a year, including a client unsupervised/neglected in facility van at a Staff member’s home, improper restraint of a client by a Staff member at facility, and verbal abuse of a client by a Staff member at facility. Additionally, indications of personal rights abuses including interference of daily living functions of a client were supported through interview testimonial evidence collected. On 09/20/2023, the facility was cited for previous case management incident with a Type A deficiency for Personal Rights, Title 22 (22 CCR) Division 6, Chapter 1 Section 80072(a)(3). The plan of correction implemented for previous Case Management incident(s) by Licensing included Licensee conducting and providing evidence of Client Personal Rights Training for all Staff. The previous Plan of Correction by Tri-Counties Regional Center (TCRC) included monitoring compliance with a Corrective Action Plan implemented by TCRC through scheduled and unannounced visits to the facility as well as other correspondence with the facility administrator. The facility provided evidence to both the LPA and TCRC of Mandated Reporter Training, SIR Triage & Reporting Training, Intellectual & Developmental Disabilities (ID/DD) Compliance Training, and Special Incident Reporting Training taking place on the dates of 09/26/2023 and 09/27/2023. Additionally, the Licensee provided the LPA and TCRC with evidence of Personal Rights of Clients & Mandated Reporter Requirements Training by an expert qualified trainer taking place on 10/25/2023. S1 stated to the LPA and TCRC representative that S4 was a Staff member at the facility who participated in all the previously required training as part of the previous plan of correction.

Further investigation is needed into this Case Management Incident occurring on 04/01/2024 with the allegation of physical harm committed against a client in care by a Staff member at the facility.

No health and safety hazards noted at this time, and no citations were issued. Exit interview conducted. Copy of the Report issued to the facility.