Complaint Investigation Report

and Personnel Report (Dated: 08/01/2023), Criminal Record Statement (Dated: 08/01/2023), First Aid Certificate (Dated: 04/08/2023), Health Screening Report (Dated: 01/23/2024), Designation of Facility Responsibility (Dated: 10/02/2024), and Administrator Certificate (Dated: 04/25/2024-01/16/2026) for staff were obtained from the facility.

The investigation revealed the following: Allegation #1- Facility violated their fire clearance.

The details of the complaint alleged that the facility violated their fire clearance by having a non-ambulatory client in a facility that was only fire clearance cleared for ambulatory clients. On 10/02/24, from 09:30am-2:00pm, LPA interviewed staff (S1-S4) and clients (C1-C3) regarding the allegation. 4 of 4 staff denied the allegation that the Facility violated their fire clearance. All staff (S1-S4) stated that all clients in the facility are ambulatory, and that they have never violated the fire clearance by having a non-ambulatory client in care.

LPA interviewed clients C1-C3 about the allegation and 3 of 3 clients denied the allegation that the Facility violated their fire clearance. All clients verified that they could walk without assistance. LPA observed that all clients (C1-C3) were able to ambulate without assistance from staff. LPA further observed that (C1-C3) were able to ambulate from the facility van where they were returning from their day program, and ambulate into the facility, into their bedrooms, and move around the facility without staff intervening to help with assistance. LPA reviewed Ambulatory Statements (Dated: 07/05/2016, 08/19/2011, & 02/04/2013) and Physicians Reports (Dated: 04/19/2024, 04/05/2024) for clients (C1-C3) that shows that all clients in the facility are ambulatory.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Facility violated their fire clearance. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated .

Allegation #2- Facility staff restrain clients with their clothing to prevent behaviors.

The details of the complaint alleged that the facility staff and the administrator tie the consumer's (C1) long-sleeved PJ over C1s hand during sleep hours to prevent C1 from skin picking during C1s sleep. On 10/02/24, from 09:30am-2:00pm, LPA interviewed staff (S1-S4) and clients (C1-C3) regarding the allegation. 4 of 4 staff denied the allegation that Facility staff restrain clients with their clothing to prevent behaviors.