Complaint Investigation Report

The Investigation revealed the following:

Allegation: Staff inappropriately handled residents in care.

It is alleged that on either 3/29/2026 or 4/5/2026 S1 got upset with C1 and grabbed C1 inappropriately by the wrist. LPA interviewed 8 staff and 5 staff denied the allegation. Interview with S6 revealed they were present during the incident, S6 was cooking at the time and witnessed C1 leave the kitchen/dining area S1 followed, shortly after they heard S1 call for assistance and upon arriving to the living room S6 saw both S1 and C1 on the floor, S1 was on top of C1 and holding C1 by the wrist with C1’s arm behind their back and C1 was pulling on S1’s shirt. S6 stated that they told S1 to stop and get off C1 as they can hurt them and S1 removed their grip on C1’s wrist and removed their shirt to get away from C1 as C1 would not let go of S1’s shirt. C1 then went to their room and the behavior de-escalated. Interview with S1 revealed that the incident occurred, S1 stated that they are aware they may have not followed the proper protocol and did not restrain C1 in attempt to harm them but in attempt to keep C1 from hitting and scratching them. S1 also stated that they ran after C1 when C1 left the dining room and knew C1 was already experiencing a behavioral episode, S1 stated that this may have been what caused C1’s behavior to escalate, regrets following C1 to their room and should have allowed C1 time to calm down. LPA interviewed 1 witness and they confirmed that there was an incident that occurred but could not get much detail from C1 as C1 has a hard time communicating the exact events of the incident. W1 stated that C1 has aggressive behaviors that begin mild and will decrease when given space, however, if C1 is being followed or feels threatened the behaviors will increase. W1 confirmed that a body check was performed on 4/30/26 and there was no evidence of redness or bruising on C1. LPA reviewed SIR that the department received on 4/28/26 stating that on 4/23/26 a Sheriff arrived at facility to speak with both C1 and S1 and that S1 would be released from duties for further investigation. LPA interviewed 2 clients and both denied the allegation, C1 stated they do not know who S1 is and that staff have never mistreated or handled them inappropriately. LPA reviewed C1’s IPP and Behavioral Service Plan, both indicated that C1 experiences aggressive behaviors that last up to 10 minutes, soothing C1 and providing support are things that can be done to decrease the behaviors. There was nothing noted in the IPP or the Behavioral Service Plan that explained the proper protocol on how to de-escalate C1’s aggressive behavior. Interviews with 8 staff and 2 witnesses confirmed that when a client is experiencing a behavioral episode like this, time and space should be provided so the clients can calm down.

Based on LPAs interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 3 are being cited on the attached LIC 9099D. Exit interview held, and a copy of this report and appeal rights were provided.