Complaint Investigation Report

Staff restrained client without the authority to do so.

The alleged allegation occurred on 02/20/2025 at R1’s Day Program. W2 reported what was relayed to him/her from W1 to the Contra Costa County Sheriff's Department, and law enforcement was dispatched on 02/27/2025. ADM provided LPA with proof of communications regarding R1 that included text messages, emails, attendance records, and LIC 624 which were all related to R1's behavioral history from 2024 to 2025. Interviews and statements from S1, S2, S3, S4, W1, and W2, and the history report for the police incident did not reveal that any staff hit R1, or any other Clients. S1 had not received any written or oral communications from W1 or W2 regarding the allegation to investigate any wrong doings prior to 02/27/2025. Staff are trained for crisis intervention, exercises environmental restraints, verbal and non-verbal redirecting.

Staff applied essential oils to client’s skin without a physician’s order.

W2 stated that S1 applied an essential oils lotion to R1’s skin. S1 and LPA toured the facility and S1 presented scented air diffusion that is centrally located at the entrance of the facility and the contents remains locked in the facility. S2 has locked lotions that are available to staff and residents upon request. W1 and W2 could not provide any date, times or witnessing of an application of essential oils to C1. S1 stated that he/she has used the same products since the facility has opened 05/2024, has given lotion and hand sanitizers as gift bags, and not at any time was S1 made aware of any grievances surrounding the products.