Section 1 of 1 in this document

INLAND REGIONAL CENTER

SIR/OBSERVATION REPORT (May 2026)

Before beginning, let's determine if you are reporting a HIPAA violation.

HIPAA violations occur when a person responsible for securing consumer information/records either:

Discloses a consumer's personal information without proper authorization
Loses a consumer's personal information, or
When the consumer's personal information is breached/stolen

Are you reporting a HIPAA violation or SIR/Observation Report?

HIPAA violation

SIR or Observation Report

ATTENTION!!!

Please do not complete an SIR.

Instead, please click this link which will redirect you to IRC's HIPAA Violation Report form:

https://inlandrc.seamlessdocs.com/f/ICRC385

Now, let's determine if you are reporting an allegation of abuse, neglect, or victim of crime.

Are you reporting an allegation of abuse or neglect or victim of crime?

YES

Which are you reporting?

Abuse or Neglect (cross report to APS/CPS/LTCO)

Victim of Crime (cross report to Law Enforcement)

Have you or someone on the consumer's behalf filed mandated reports to any mandated reporting agencies?

YES

Which mandated agencies have been notified? (If licensed, remember to also notify the proper licensing agency)

Adult Protective Services (APS)

Child Protective Services (CPS)

Law Enforcement

Long-term Care Ombudsman (LTCO)

ATTENTION!!!

As a mandated reporter, you are required by law to notify and file a report with the appropriate investigative agency or agencies designated to receive mandated reports IN ADDITION to completing this SIR.

Please complete the mandated reports before completing this SIR - Complete the SIR after you have filed the mandated reports so you can document your investigative agency notifications. All reports - mandated reports and SIR - must be completed IMMEDIATELY.

All allegations of abuse and neglect MUST be reported to mandated reporting agencies. In some cases, you may also need to notify law enforcement.

All victim of crime situations MUST be reported to law enforcement.

If abuse or neglect occurred in:	Notify these agencies:
Residential facility or ICF (Adults)	APS and LTCO
Residential facility or ICF (Children)	CPS
Other service types and consumer is a minor	CPS
Other service types and consumer is an adult	APS

MANDATED REPORTING CONTACTS

ADULT PROTECTIVE SERVICES (APS)

Riverside County

Dept. of Public Social Services-Adult

4060 County Circle Drive

Riverside, CA 92501

Phone: (800) 491-7123

Online Reporting Portal: www.reporttoaps.org -OR

Google Reporting Form “SOC 341” and FAX (951) 358-3969

San Bernardino County

Department of Aging & Adult Services

686 East Mill Street

San Bernardino, CA 92415

Phone: (877) 565-2020

Online Reporting Portal: www.reporttoaps.org -OR

Google Reporting Form “SOC 341” and FAX (909) 948-6215 or EMAIL: DAAS-PGAPSCallCenter@hss.sbcounty.gov

LONG-TERM CARE OMBUDSMAN (LTCO)

Riverside County	9121 Haven Avenue, Suite 220 Rancho Cucamonga, CA 91730 Phone: (833) 772-6624	Google Reporting Form “SOC 341” FAX (909) 204-4141
San Bernardino County	LTC Ombudsman Program 748 East Hospitality Lane San Bernardino, CA 92408 https://wiseombudsman.org/ County Wide Complaints/Reporting Phone: (800) 334-9473 San Bernardino Office Phone: (909)332-6490 Office Fax: (909) 332-6495 High Desert Office Phone: (760)243-8404 Office Fax: (760) 780-4141	Google Reporting Form “SOC 341” FAX (909) 332-6495 or (760) 780-4141

CHILD PROTECTIVE SERVICES (CPS)

Suspected Child Abuse Reporting Form: https://oag.ca.gov/sites/all/files/agweb/pdfs/childabuse/ss_8572.pdf?

Riverside County

Phone: (800) 442-4918

Call and complete the form. The CPS agent will provide an email/mailing address/fax to submit the form to Child Protective Services.

San Bernardino County

Phone: (800) 827-8724

Call and complete the form. Then fax form to “Attention: Child Abuse Hotline” to (909) 891-3545 or (909) 891-3560

LAW ENFORCEMENT (LE)

Riverside and San Bernardino Counties	911
Please Note: For non-emergency situations, please contact the local law enforcement agency directly by searching the contact number for the local city police department online

REPORT DETAILS

Date VENDOR/OTHER ENTITY first learned of incident

Date CSC was notified of incident

REPORTING PARTY DETAILS

Who is completing the SIR/Observation Report?

VENDOR OR LONG-TERM HEALTH CARE FACILITY

IRC STAFF

Name of Reporting Agency/Facility/Program

Name of Agency/Facility/Program

Type of Reporting Agency/Facility/Program

Type of Agency/Facility/Program

Other Vendor Type

What is the level or type of CCF home?

Address of Reporting Agency/Facility/Program

Address of Agency/Facility/Program

IRC Vendor Number of Reporting Agency/Facility/Program

IRC Vendor Number of Agency/Facility/Program

Phone Number of Reporting Agency/Facility/Program

What is the name of your program's IRC Liaison?

What is the name of this program's IRC Liaison?

Licensing Facility File Number (if licensed by CCL or DHS/DPH)

Were you or staff present and/or scheduled to provide services at the time of incident?

YES

Was vendored staff present and/or scheduled to provide services at the time of incident?

YES

CONSUMER DETAILS

To which program does this consumer belong?

Adult or Senior

Transition

Children or Preschool

Early Start or Intake

What is the case status of this consumer?

2 - Active

1 - Early Start

U - Provisional

0 - Intake

Is this consumer involved in the Self-Determination Program (SDP)?

YES

Consumer's UCI Number

Is this a consumer of IRC?

Yes

What is the name of the consumer's IRC Consumer Services Coordinator (CSC)?

If this consumer's case is affiliated with another Regional Center (RC), please identify which one:

INCIDENT DETAILS

Date of Incident

Is the date approximate?

YES

Time of Incident

Time of Day

Unknown

Is the time of incident approximate?

YES

Where did the incident occur?

Other Location of Incident

Name of place where incident occurred

What is the address of the incident location?

Were there any witnesses to the special incident?

Please list the name(s) and address(es) of witness(es)

Observation Reports (select all that apply)

Consumer was arrested

Consumer choked on food

CPI Restraint (or other approved restraint methods)

New health condition

Vehicular accident

Violation of rights

What type of neglect is alleged to have occurred?

Failure to prevent ABANDONMENT

Failure to exercise the degree of care that a reasonable person in a like position of having the care or custody of an individual served

Failure to prevent MALNUTRITION or DEHYDRATION

Failure to provide MEDICAL CARE for physical and mental health needs, including failing to administer required health care interventions

Failure to assist in PERSONAL HYGIENE (including failure to assist with toileting or incontinency needs)

Failure to provide FOOD, FLUIDS, CLOTHING, or SHELTER

Failure to PROTECT from health and safety hazards, including failing to prevent two or more falls in a thirty (30) day period

Any incident of alleged neglect reported pursuant to the Elder and Dependent Adult Abuse Reporting Act commencing with Welfare and Institutions Code section 15600 or the Child Abuse and Neglect Reporting Act commencing with Penal Code section 11164

Describe the most recent fall and if the consumer suffered any injuries. Please list the injuries and treatments

Why did the consumer fall?

Dizziness

Seizure

Tripped

List how many falls the consumer had in the last 30 days

Were these falls were preventable?

Were these falls were preventable?
Question	Yes	No	Unknown
Fall 1	Fall 1 - Yes	Fall 1 - No	Fall 1 - Unknown
Fall 2	Fall 2 - Yes	Fall 2 - No	Fall 2 - Unknown
Fall 3	Fall 3 - Yes	Fall 3 - No	Fall 3 - Unknown
Fall 4	Fall 4 - Yes	Fall 4 - No	Fall 4 - Unknown
Fall 5	Fall 5 - Yes	Fall 5 - No	Fall 5 - Unknown
Fall 6	Fall 6 - Yes	Fall 6 - No	Fall 6 - Unknown
Fall 7	Fall 7 - Yes	Fall 7 - No	Fall 7 - Unknown
Fall 8	Fall 8 - Yes	Fall 8 - No	Fall 8 - Unknown
Fall 9	Fall 9 - Yes	Fall 9 - No	Fall 9 - Unknown
Fall 10	Fall 10 - Yes	Fall 10 - No	Fall 10 - Unknown

If some of these falls were preventable, please describe how they could have been prevented

What is the plan to prevent future falls?

If reporting an allegation of abuse, what is the relationship of the perpetrator to the consumer?

If reporting an allegation of neglect, what is the relationship of the perpetrator to the consumer?

If reporting an allegation a victim of crime, what is the relationship of the perpetrator to the consumer?

Description of alleged perpetrator, if known (i.e. name, address, age, physical description, etc.)

What type of medication error occurred?

Missed dose

Wrong dose

Wrong medication

Wrong person

Wrong time

Wrong route

Documention error (i.e. the MAR was not initialed)

Consumer refused medications

Was medical attention needed?

Consulted RN/RPH/MD

Consulted Poison Control

Emergency room/Urgent care visit

Observe/Report

None

Who did not administer the medications properly?

Staff of vendor

Relative/Family member

Consumer

Pharmacy and/or insurance issues

What is the plan to work with the consumer to mitigate refusals?

Based on the number of medications prescribed, should this consumer be referred to IRC's pharmacologist to review?

YES

Describe the Circumstances of the Consumer's Death

Was the cause of death any of the following?

disease related

non-disease related

unknown

What were the circumstances leading up to the consumer's death?

Describe the nature of medical treatment and where administered.

Was law enforcement notified of this missing person event? (check all that apply)

Consumer always remained in staff's line of sight/staff shadowed consumer during entire incident

YES - Law enforcement was notified

NO - Law enforcement was NOT notified

Please provide the police report number if one was given to you

Has the consumer already been found?

YES - The consumer has already been found

NO - The consumer is still missing

Was medical treatment beyond first aid required? (i.e. injury required a visit to ER or urgent care)

YES

What were the discharge instructions?

Where on the body did the bruising, contusion, or hematoma occur?

Head

Eyes

Neck

Breasts

Genitals

Rectal or anal area

What is the size of the bruise, contusion, or hematoma?

What kind of treatment did the laceration require?

Skin glue/adhesive

Staples

Sutures or stitches

Bandages (i.e. Band-Aids or Steri-Strips)

None of the above (Treatment was NOT required)

Please tell us more about the hospitalization...

Consumer was admitted inpatient to the hospital

Consumer was treated only in the ER or urgent care and was NOT admitted inpatient

What were the discharge instructions?

What was the reason for the psychiatric emergency?

5150 (72-hour involuntary psychiatric hold)

5250 (14-day involuntary psychiatric hold)

Anxiety

Altered mental status

Substance use disorder

Has the consumer already been discharged?

YES - Consumer has been discharged

NO - Consumer is still hospitalized

UNKNOWN

What were the discharge instructions?

What DATE was the consumer discharged?

What TIME was the consumer discharged?

Time of day

Approximate

OTHER AGENCIES OR INDIVIDUALS NOTIFIED AND/OR INVOLVED

Method used to report to APS

Phone report

Online report

Faxed report

Date report was made to Adult Protective Services

If a reference/confirmation number was provided by APS, please enter it here:

If APS provided a response, please state what they said here:

Method used to report to CPS

Phone report

Online report

Faxed report

Date report was made to Child Protective Services

If a reference/confirmation number was provided by CPS, please enter it here:

If CPS provided a response, please state what they said here:

Name of individual contacted at Community Care Licensing

Date report was made to Community Care Licensing

Name of individual contacted at Coroner

Date report was made to Coroner

Name of individual contacted at Department of Public Health/Department of Health Services

Date report was made to Department of Public Health/Department of Health Services

Method used to report to Law Enforcement

Phone report

Online report

Faxed report

Date report was made to Law Enforcement

If a reference/confirmation/case number was provided by law enforcement, please enter it here:

If Law Enforcement provided a response, please state what they said here:

Method used to report to Long-Term Care Ombudsman

Phone report

Online report

Faxed report

Date report was made to Long Term Care Ombudsman (LTCO)

If a reference/confirmation number was provided by the LTCO, please enter it here:

If LTCO provided a response, please state what they said here:

Name of individual contacted - Parent/Guardian/Conservator

Date report was made to Parent/Guardian/Conservator

Name of individual and relation to consumer contacted - Other #1

Date report was made to Other #1

Name of individual and relation to consumer contacted - Other #2

Date report was made to Other #2

DESCRIPTION OF INCIDENT AND ACTIONS TAKEN

What happened? (In your words, please describe the incident in DETAIL - i.e. describe what led up to the incident; what happened during; and what happened after)

What preventative actions were taken or planned, if any?

Staff on administrative leave or terminated

Policies revised

Staff training

Does not apply

Please explain the preventative actions taken or planned in further detail

Have previous SIRs or Observation Reports for THIS consumer been reported to the Regional Center within the last 90 days?

YES

Please list the dates of these reported incidents for this consumer that occurred within the last 90 days

ATTACHMENTS

Would you like to attach supporting documents and/or photos to this report?

YES

Add attachments, photos, or documents here

INFORMATION OF PERSON COMPLETING REPORT

Name of person completing report

Job title of person completing report

Name of Vendor/Agency/Facility/Program with which person completing report is affiliated

Phone Number of person completing report

Work email address of person completing the report (or email address of vendor/facility/program)

ALMOST DONE! Please review the following before submitting.

REMINDERS

Once the submit button is clicked, please note that the SIR/OR is automatically delivered to IRC. Do not fax or email a copy of the SIR/OR to IRC.

After submitting, remember to print and retain a copy of the completed report in the consumer's file.

If licensed, please fax a copy of the report to the appropriate licensing agency.

SUBMITTING THE REPORT

To finalize and submit the report, click the SUBMIT button (lower right hand corner).

Are you reporting a HIPAA violation or SIR/Observation Report?

Are you reporting an allegation of abuse or neglect or victim of crime?

Which are you reporting?

Have you or someone on the consumer's behalf filed mandated reports to any mandated reporting agencies?

Which mandated agencies have been notified? (If licensed, remember to also notify the proper licensing agency)

REPORT DETAILS

Date VENDOR/OTHER ENTITY first learned of incident

Date CSC was notified of incident

REPORTING PARTY DETAILS

Who is completing the SIR/Observation Report?

Were you or staff present and/or scheduled to provide services at the time of incident?

Was vendored staff present and/or scheduled to provide services at the time of incident?

CONSUMER DETAILS

To which program does this consumer belong?

What is the case status of this consumer?

Is this consumer involved in the Self-Determination Program (SDP)?

Consumer's Name

Consumer's Date of Birth

Is this a consumer of IRC?

INCIDENT DETAILS

Date of Incident

Is the date approximate?

Time of Day

Is the time of incident approximate?

What type of incident occurred? (select all that apply)

Observation Reports (select all that apply)

What type of crime occurred?

What type of abuse is alleged to have occurred?

What type of neglect is alleged to have occurred?

Why did the consumer fall?

Were these falls were preventable?

What type of medication error occurred?

Was medical attention needed?

Who did not administer the medications properly?

Based on the number of medications prescribed, should this consumer be referred to IRC's pharmacologist to review?

Describe the Circumstances of the Consumer's Death

Was the cause of death any of the following?

Please select any possible causes of death, if known:

Please specify the cause, if known

Medical Device Utilization - Please select any medical devices used long-term by the individual who passed

Care Characteristics - Please select any circumstances that may apply to the consumer's death

Was law enforcement notified of this missing person event? (check all that apply)

Has the consumer already been found?

What type of injury or accident occurred?

Was medical treatment beyond first aid required? (i.e. injury required a visit to ER or urgent care)

Where on the body did the bruising, contusion, or hematoma occur?

What kind of treatment did the laceration require?

What type of hospitalization occurred?

Please tell us more about the hospitalization...

What was the reason for the psychiatric emergency?

Has the consumer already been discharged?

What DATE was the consumer discharged?

Time of day

OTHER AGENCIES OR INDIVIDUALS NOTIFIED AND/OR INVOLVED

Who was notified of the incident (Please check all that apply)?:

Method used to report to APS

Date report was made to Adult Protective Services

Method used to report to CPS

Date report was made to Child Protective Services

Date report was made to Community Care Licensing

Date report was made to Coroner

Date report was made to Department of Public Health/Department of Health Services

Method used to report to Law Enforcement

Date report was made to Law Enforcement

Method used to report to Long-Term Care Ombudsman

Date report was made to Long Term Care Ombudsman (LTCO)

Date report was made to Parent/Guardian/Conservator

Date report was made to Other #1

Date report was made to Other #2

DESCRIPTION OF INCIDENT AND ACTIONS TAKEN

What preventative actions were taken or planned, if any?

Have previous SIRs or Observation Reports for THIS consumer been reported to the Regional Center within the last 90 days?

ATTACHMENTS

Would you like to attach supporting documents and/or photos to this report?

Add attachments, photos, or documents here

INFORMATION OF PERSON COMPLETING REPORT

ALMOST DONE! Please review the following before submitting.