Complaint Investigation Report

The investigation revealed the following:

Regarding the allegation: Client sustained multiple bruises due to staff neglect or physical abuse . It was alleged that FM reported concerns about possible physical abuse after noticing bruising on C1's arm since January 2025. Since then, C1 has returned home with more bruises on the inner arm and forearm. All staff interviewed denied the allegation. S1 stated that facility has 'hands-off policy' and paws not claws approach and staff are trained to verbally redirect the clients. S1 stated that FM called the program on February 06, 2026 to report their concerns about C1's bruises, which they had noticed since January 2025. S1 conducted an internal investigation and found out that FM had reported and sent photos of C1's bruises to S4 in January but failed to report it to S1. Staff stated that C1 is very routine oriented and has elopement behavior, sometimes leaving the supervised area without permission. Interview with S3 revealed that on February 4, 2026, S3 was assigned to C1 where C1 was having behavioral issues such as yelling and forcefully pushing through staff and doors with his arms. S3 held C1's arm to redirect them. And while outside the building, cars were coming in and C1 was trying to leave the area without warning. Due to instinct, S3 grabbed C1’s arm to keep C1 safe. This was witnessed by S4 who corrected and reminded S3 of the hands-off policy, and to verbally redirect clients instead. Interview with S3 and S4 revealed that the intervention was a necessary ‘safety’ hold rather than intentional harm. Because C1 demonstrated a behavioral risk of eloping, S3 responded quickly by grabbing C1’s arm, preventing C1 from danger, and not due to neglect or physical abuse. S4 indicated that as S3 was new, S3 grabbed C1’s arm without malice or excessive force. Interviewed clients denied the allegation and stated that no one has harmed them and they never sustained bruises due to staff’s neglect or physical abuse. Interview with FM revealed that the bruises s tarted back in January with date stamped photos as evidence. San Gabriel Pomona Regional Center's investigation was inconclusive. Therefore, there was insufficient evidence to corroborate the allegation of staff neglect or physical abuse.

Based on statements and interviews conducted with clients and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation.

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.

Exit interview conducted and a copy of this report was provided to Michael Santos, Program Director.