Complaint Investigation Report

(Continued from LIC9099) LPA also reviewed facilities Plan of Operation regarding Emergency Intervention Plan and Crisis Intervention Training. On 02/04/2025 LPA Rios conducted an initial complaint visit for complaint control # 31-AS-20250131102020. During that visit LPA conducted interviews with eight (8) staff of which for (4) had already been interviewed for this complaint during previous visits. LPA Rios conducted another subsequent visit on 08/04/2025 and from approximately 12:05 p.m. to 12:30 p.m., LPA interviewed the administrator, Chary Hallon and Client #2 (C2). On 10/06/2025 LPA interviewed the Behavior Consultant from Mountain Light, Inc. regarding facility’s communication with them.

Allegation: Staff make verbal threats to residents. It was alleged that Client #1 (C1) contacted emergency services, and when they arrived staff told the paramedics that C1 was fine and later threatened to assault C1 if they attempted to call again.

Interview with C1 supported the allegation stating that after an incident with S1, Staff#1 (S1) was upset C1 had contacted 911 and then threaten to assault C1 if C1 called 911 again. Interview with eight (8) staff denied witnessing C1 being threatened by S1. LPA’s Interview with S1 denied the allegation. Interview, C2 denied witnessing S1 threaten C1. Review of Special Incident Reports (SIRs) regarding C1 from 10/2024 to 01/2025 revealed C1 had episodes of verbal aggression and making threats about reporting staff. C1’s IPP revealed C1 has disruptive behaviors that interfere with social participation almost every day. LPAs interview with staff and C2 corroborate C1 threatens staff and uses profanity towards staff and other clients. LPA reviewed the information documented in the complaint intake, which included a report from Deputy Mendoza of the Lancaster Sheriff’s Department. According to the report dated 01/15/2025, Deputy Mendoza responded to the facility regarding resident C1. He spoke with C1, who stated they were fine, enjoyed living at the facility, and did not require any assistance from the deputy. Deputy Mendoza also spoke with a staff member who reported being unaware of any incident or concerns. No additional information was provided.

LPA was unable to find a witness to the allegation that S1 threatened to assault C1 if they contacted 911 again. Therefore, based on interviews, and document reviews, this allegation is deemed Unsubstantiated at this time.