Complaint Investigation Report, 04/23/2025

During the investigation, W1 stated during interview, W1 witnessed staff member disrupted C1’s environment by moving C1’s mattress to the floor and rearranging of furniture. W1 says the last time she read the client’s individualization Behavior Support Plan (IBSP) was when C1 was admitted to Cypress House a couple of years ago. S1, S2, and S3 stated during interview C1 IBSP addresses the removal of mattress from the bed to the floor when C1 is having a behavior and wants the mattress removed. Staff also stated, C1 has likes to remove his mattress from the bed and place on the floor to sleep. LPA reviewed C1’s IBSP dated January 13,2025 which indicated rearranging of furniture (mattress) is okay when C1 is having a behavior and demands the mattress to be moved. LPA observed the plan was approved by C1’s Behaviorist, Regional Center of East Bay (RCEB), Telecare, DDS and client’s rights (CR).

Allegation: Staff inappropriately handled client

During the investigation, W1 stated she didn’t witness any inappropriate handling towards client (C1) and that her staff did. LPA was unsuccessful in interviewing the other hillside staff members. S1 and S2 added that after C1 had an episode (vomiting), they both placed C1 in the shower and dressed C1 with clean clothing, prior to leaving the facility. S1 and S2 also stated during interview, has not witnessed any staff members inappropriately handling any clients in care and that all of the staff at cypress follows C1's IBSP.

Allegation: Staff was verbally aggressive towards client

During the investigation, W1 stated she witnessed staff being verbally aggressive towards C1 by yelling at C1 when C1 was having a behavior. S1 stated during the interview staff’s interactions with C1 are all based on C 1’s IBSP, and the ongoing training Telecare provides to staff on a regular basis. S1 also stated, the facility staff and are support team for C1 works hard and meet regularly to implement plans that would work for C1. LPA reviewed C1’s IBSP and it revealed that staff should use a firm, but calm voice as part of C1’s interventions.