Complaint Investigation Report

Allegation: Client sustained unexplained injuries due to staff abuse or neglect.

It is alleged that the client sustained unexplained injuries. During staff interviews, staff reported no observed incidents that could have caused the injuries. Multiple staff indicated that the bruising was discovered without a known cause. Staff stated the client was unable to explain how the injuries occurred and was observed to be acting normally with no complaints of pain. Staff reported the incident to the administrator, and the client was taken for medical evaluation.

It should be noted that, of the five (5) clients interviewed, two (2) were nonverbal and two (2) had cognitive limitations, which impacted their ability to provide information. During client interviews, clients did not report witnessing any incident involving Client 1 (C1). C1 was unable to explain how the injuries occurred and demonstrated limitations in responding to questions. Other clients expressed no concerns regarding staff care or safety within the facility.

.Allegation: Staff falsified an incident regarding client.

It is alleged s taff falsified or misrepresented information related to an incident involving C1. During staff interviews, Staff reported that the incident was documented and reported to the appropriate agencies, including the San Gabriel/Pomona Regional Center. No staff indicated that information was altered or falsified. During client interviews Clients did not provide statements that support the allegation.

Allegation: Staff do not ensure that clients are provided an adequate quantity of food.

It is alleged s taff do not ensure that clients are provided with an adequate quantity of food. During the initial visit conducted on 04/09/2026, the facility did not have an adequate supply of food available; however, a grocery delivery was observed at the time of the visit. During the current visit conducted on 04/23/2026, the facility was observed to have a sufficient supply of food on hand. During staff interviews, staff reported that meals are prepared daily, often from scratch, and that clients are allowed to request additional portions at any time. Staff stated there are no restrictions on food access and that snacks are available throughout the day upon request. During client interviews, clients reported satisfaction with the food provided. Clients stated they are able to request additional food if desired and have access to snacks. No clients expressed concerns regarding food quantity or availability.

Allegation: Staff mishandle client's P&I funds.

It is alleged that staff mishandle clients’ Personal & Incidental (P&I) funds, including use of funds for items not supported by receipts or proper documentation. During staff interviews, staff reported that the licensee is responsible for managing and reconciling P&I funds. Staff indicated they may assist with distributing funds to clients and documenting transactions but do not oversee financial management. Staff reported no knowledge of discrepancies or concerns.